Disability in patients with end-stage liver disease: Results from the functional assessment in liver transplantation study

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

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

Frailty in liver transplantation: Exploring prescribing exercise as medicine to improve patient outcomes

Liver transplantation (LT) represents a curative avenue for individuals with advanced chronic liver disease. Given the inherent illness severity of LT candidates, identifying patients at greater risk for adverse outcomes before and after transplantation is paramount. Approximately 50% of cirrhotic patients are frail and have considerable functional impairment. Various measures have been used to assess frailty, including performance-based tests and functional status evaluations. Frailty carries significant prognostic implications and predicts both mortality and pre- and post-LT complications. Contributing factors to frailty in this population include sarcopenia, malnutrition, inflammation, and psychosocial factors. Recognizing the prevalence of frailty among LT candidates, exercise interventions have been developed to improve physical frailty and offer potential to improve patient outcomes. While many interventions have demonstrated efficacy without notable adverse events, the absence of a universally accepted standard for exercise prescription underscores the variability in intervention elements and patient adherence. Given the safety profile of exercise interventions, there remains a critical need for standardized protocols and guidelines to optimize exercise regimens for LT candidates. This review delves into the landscape of frailty among LT candidates, elucidating its etiological underpinnings, impact on outcomes, utilization of exercise interventions, and the efficacy of exercise programs in reducing the burden frailty in those awaiting LT.

Mental health and quality of life in patients with chronic liver disease: a single-center structural equation model

BACKGROUND

Chronic liver disease (CLD) is one of the leading disease burdens in Pakistan. Until now, there has only been limited focus in the country on providing health services through tertiary services in urban cities, whereas there is almost no research in Pakistan on the mental health and quality of life of CLD patients. This study aimed to understand which predictors influence the mental health and quality of life of CLD patients in order to advise better policy protection.

METHODS

Data was collected from CLD patients at the Pakistan Kidney and Liver Institute and Research Centre, Lahore, Pakistan. A total of 850 respondents were part of the final sample. The age of respondents ranged from 18 to 79 years and included the following diagnosis: (i) Chronic Viral Hepatitis (n = 271), (ii) Cirrhosis (n = 259), (iii) Hepatocellular Carcinoma (n = 193), and (iv) Non-viral Liver Disease (n = 127).

RESULTS

Mean results reveal that females as well as illiterate patients need more support for mental health and communication with their physician; whereas men need more support to develop coping strategies. Structural equation modelling results reveal that the severity of symptoms (β = 0.24, p < 0.001), coping strategies (β=-0.51, p < 0.001), and doctor communication (β=-0.35, p < 0.001) predict mental health. Quality of life is associated with the severity of symptoms (β=-0.36, p < 0.001), coping strategies (β = 0.26, p < 0.05), and doctor communication (β = 0.09, p < 0.05).

CONCLUSIONS

A 'bio-psycho-social-spiritual' model is recommended for Pakistan's CLD patients which includes the integration of social officers to provide support in four key areas to secure mental health and quality of life of patients.

Association of chronic conditions and physical multimorbidity with new-onset incontinence in a nationwide prospective cohort study of older adults ≥ 50 years in China

BACKGROUND

The relationship between multimorbidity (i.e. ≥ 2 chronic conditions) and incontinence (i.e. urinary and/or faecal incontinence) is underexplored. This study investigated the association between multimorbidity and incident incontinence in Chinese adults aged ≥50 years.

METHODS

Data from the 2011 and 2015 waves of the China Health and Retirement Longitudinal Study were used. The association between 12 chronic conditions, multimorbidity and new-onset incontinence was analysed using weighted logistic regression models. Mediation analysis was conducted to explore the potential mediators (self-reported health, subjective memory, depressive symptoms, disability, cognitive function, handgrip strength, mobility limitations, medications and frailty status) between multimorbidity and incontinence.

FINDINGS

Among 9,986 individuals aged ≥50 years who were continent at baseline, 5.3% (n = 521) were newly incontinent 4 years later (incident cases). The risk of incident incontinence increased with physical multimorbidity (OR 2.04, 95% CI 1.62-2.57). Compared to no chronic condition, having 1, 2, 3 and ≥ 4 chronic conditions were associated with incident incontinence with OR (95% CI): 1.41 (1.01-1.97), 1.74 (1.24-2.44), 2.82 (1.93-4.12) and 3.99 (2.29-6.95), respectively. The association between multimorbidity and incontinence was mediated by self-reported health (41.2%), medications (26.6%), mobility limitations (20.9%), depressive symptoms (12.8%), disability (11.6%), subjective memory (8.7%) and frailty status (8.3%).

CONCLUSION

This longitudinal study found that physical multimorbidity and specific chronic conditions may increase the risk of new-onset incontinence among Chinese adults aged ≥50 years. Self-reported health, medications and mobility limitations seemed to be important intermediate conditions between multimorbidity and incident incontinence.

Caregiver Burden in Adult Solid Organ Transplantation

The informal caregiver plays a critical role in supporting patients with various end-stage diseases throughout the solid organ transplantation journey. Caregiver responsibilities include assistance with activities of daily living, medication management, implementation of highly specialized treatments, transportation to appointments and treatments, and health care coordination and navigation. The demanding nature of these tasks has profound impacts across multiple domains of the caregiver's life: physical, psychological, financial, logistical, and social. Few interventions targeting caregiver burden have been empirically evaluated, with the majority focused on education or mindfulness-based stress reduction techniques. Further research is urgently needed to develop and evaluate interventions to improve caregiver burden and outcomes for the patient-caregiver dyad.

Liver transplantation in the patient with physical frailty

Frailty is a decline in functional reserve across multiple physiological systems. A key component of frailty is sarcopenia, which denotes a loss of skeletal muscle mass and impaired contractile function that ultimately result in physical frailty. Physical frailty/sarcopenia are frequent and contribute to adverse clinical outcomes before and after liver transplantation. Frailty indices, including the liver frailty index, focus on contractile dysfunction (physical frailty), while cross-sectional image analysis of muscle area is the most accepted and reproducible measure to define sarcopenia. Thus, physical frailty and sarcopenia are interrelated. The prevalence of physical frailty/sarcopenia is high in liver transplant candidates and these conditions have been shown to adversely impact clinical outcomes including mortality, hospitalisations, infections, and cost of care both before and after transplantation. Data on the prevalence of frailty/sarcopenia and their sex- and age-dependent impact on outcomes are not consistent in patients on the liver transplant waitlist. Physical frailty and sarcopenic obesity are frequent in the obese patient with cirrhosis, and adversely affect outcomes after liver transplantation. Nutritional interventions and physical activity remain the mainstay of management before and after transplantation, despite limited data from large scale trials. In addition to physical frailty, there is recognition that a global evaluation including a multidisciplinary approach to other components of frailty (e.g., cognition, emotional, psychosocial) also need to be addressed in patients on the transplant waitlist. Recent advances in our understanding of the underlying mechanisms of sarcopenia and contractile dysfunction have helped identify novel therapeutic targets.

Frailty as a predictor of poor outcomes among patients awaiting liver transplant: a systematic review and meta-analysis

Aim

This review sought to evaluate the significance of a functional assessment for liver transplant candidates, i.e., frailty, in the pre-transplant setting and its association with mortality and morbidities.

Background

Liver transplantation (LT) remains the treatment of choice for patients with end-stage liver disease. Due to the shortage of organs for LT, a careful selection of suitable recipients is essential. Frailty, a measure of physiologic reserve and increased vulnerability to stressors, was initially used in geriatrics and then introduced to the field of transplantation for better patient selection.

Methods

PubMed, Scopus, and Web of Science databases were reviewed up until January 2023. The search terms included: "frail*", "liver", and "transplant*". A Meta-analysis was conducted for the hazard ratios (HRs) obtained from the COX regression models. Fifty-five studies were included in this review; ten were included in the meta-analysis.

Results

The prevalence of frailty varied from 2.82% to 70.09% in the studies. Meta-analysis showed that overall frailty had a significant association with mortality (pooled adjusted HR [95%CI]: 2.66 [1.96-3.63]). Subgroup analyses revealed that both the Liver Frailty Index and Fried Frailty Index were significantly associated with mortality. Furthermore, these studies have demonstrated that this population's frailty is associated with ascites, hepatic encephalopathy, and esophageal varices.

Conclusion

According to emerging evidence, frailty is associated with increased morbidity and mortality of the patients on the LT waiting list. Further randomized trials are required to determine the efficacy and safety of variable interventions in the frail population.

Evaluation of liver transplant candidates with non-alcoholic steatohepatitis

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

The Effect of Dual Sensory Impairment and Multimorbidity Patterns on Functional Impairment: A Longitudinal Cohort of Middle-Aged and Older Adults in China

Objective

There is an urgent need to evaluate the contribution of several co-existing diseases on health. This study aims to explore the combined effect of dual sensory impairment (DSI) and multimorbidity patterns on functional impairment among middle-aged and older adults in China.

Methods

Data were from 10,217 adults aged 45 or older from four waves of the China Health and Retirement Longitudinal Study (CHARLS). Sensory impairments were self-reported measures. Multimorbidity patterns were identified by using k-means cluster analyses. Functional impairment was defined using activities of daily living (ADL) scale and instrumental activities of daily living (IADL) scale. Generalized estimating equation models were estimated to assess the effect of co-occurring DSI and multimorbidity on functional impairment.

Results

DSI prevalence was 50.4%, and multimorbidity prevalence was 37.7% at the baseline. The simultaneous presence of DSI and multimorbidity was associated with increased odds of ADL limitations (OR = 2.27, 95% CI: 2.11–2.43) and IADL limitations (OR = 1.89, 95% CI: 1.77–2.02). Five multimorbidity patterns were identified: the cardio-cerebrovascular pattern, the stomach-arthritis pattern, the respiratory pattern, the hepatorenal pattern, and the unspecified pattern. Compared to DSI only, DSI plus the hepatorenal pattern was most strongly associated with functional impairment (for ADL: OR = 2.70, 95% CI: 2.34–3.12; for IADL: OR = 2.04, 95% CI: 1.77–2.36).

Conclusion

Middle-aged and older adults with co-occurrence of DSI and multimorbidity are at increased risk of functional impairment, especially those with multimorbidity characterized by the hepatorenal pattern. These findings imply that integrated care for DSI and multimorbidity may be a potent pathway in improving functional status.

Low free triiodothyronine levels are associated with frail phenotype in hospitalized inpatients with cirrhosis

OBJECTIVE

Frailty is a prevalent complication predicting morbidity and mortality in cirrhosis. However, the association between thyroid hormone levels and frailty in cirrhotics remains elusive. Therefore we aimed to evaluate the relationship between thyroid hormone and frail phenotype in euthyroid patients with cirrhosis.

METHODS

A total of 214 adult cirrhotic inpatients were divided into two groups according to Frailty Index. Concentrations of free triiodothyronine (FT3), free thyroxine (FT4) and thyroid stimulating hormone (TSH) were compared. An analysis of the receiver operating characteristic (ROC) curve was implemented to determine the best cut-off for frailty. Multiple logistic regression was used to assess the association between FT3 and frailty.

RESULTS

ROC analysis indicated that the optimal cut-off to stratify frailty was FT3 <3.03 pmol/L with an area under the curve of 0.673 (95% CI: 0.582-0.764, p = 0.002), sensitivity of 81.8% and specificity of 51.9%. Patients with FT3 <3.03 pmol/L exhibited higher incidence of Child-Pugh class B/C, elevated model for end-stage liver disease score, higher creatinine, lower sodium as well as higher incidence of frailty (23.7 vs 6.0%, p < 0.001). A negative correlation was observed between FT3 values and Frailty Index (r = -0.220, p = 0.001). FT3 remained an independent risk factor for frailty after adjusting for age, Child-Pugh class, creatinine, sodium and alanine aminotransferase.

CONCLUSION

In our current study, FT3 <3.03 pmol/L were significantly associated with increased risk for frailty. Measuring FT3, a readily available biomarker, may be useful for identifying frail phenotype in euthyroid patients with cirrhosis.

Exercise physiology in cirrhosis and the potential benefits of exercise interventions: A review

Reduction in muscle mass is a highly prevalent phenomenon in cirrhosis and is now well-documented to be associated with significant morbidity and mortality. Research into muscle loss in cirrhosis remains limited by an ongoing poor understanding of its relationship with muscle function, physical activity, and aerobic capacity. Alterations in exercise physiology have been documented in studies of individuals with cirrhosis that provide important information on physical function that is not captured by simple quantification of muscle mass. Despite expert consensus recommending regular exercise in end-stage liver disease to maintain muscle mass and function, there is little evidence guiding clinicians as to which form of exercise or delivery mechanism is most effective. It also remains unproven whether any specific intervention can alter clinically relevant outcomes. This review article summarizes the available literature regarding the changes in exercise physiology observed in cirrhosis, the associated impact on physical capacity, and the results of existing trials that examine the potential benefits of exercise delivery in patients with cirrhosis, particularly pertaining to their impact on exercise physiology.

Characterization of Urine-Derived Stem Cells from Patients with End-Stage Liver Diseases and Application to Induced Acute and Chronic Liver Injury of Nude Mice Model

Urine-derived stem cells (USCs) are adult stem cells isolated from urine with strong proliferative ability and differentiation potentials. Cell transplantation of USCs could partly repair liver injury. It has been reported that the proliferative ability of bone mesenchymal stem cells in patients with chronic liver failure is significantly lower than in patients without liver disease. The aim of this study was therefore to evaluate the biological characteristics of USCs from end-stage liver disease patients (LD-USCs, USCs from patients with liver disease) compared with those from normal healthy individuals (N-USCs, USCs from normal individuals), with a view to determining whether autologous USCs can be applied to the treatment of liver disease. In this study USCs were isolated from urine samples of male patients with end-stage liver disease. Adherent USCs exhibit a spindle- or rice grain-like morphology, and express CD24, CD29, CD73, CD90, and CD146 surface markers, but not CD31, CD34, CD45, and CD105. We observed no differences in cell morphology or cell surface marker profile between LD-USCs and N-USCs. LD-USCs exhibited similar proliferative, colony-forming, apoptotic, and migratory abilities to N-USCs. Both USCs demonstrated similar capacities for osteogenic, adipogenic, and chondrogenic differentiation. When USCs were transplanted into CCl₄ treatment-induced acute and chronic liver fibrosis mouse models, we observed a decrease in liver index, recovery of alanine aminotransferase and aspartate aminotransferase levels, alleviation of liver tissue injury, and dramatic improvement of liver tissue structure. USC transplantation can effectively recover liver function and improve liver tissue damage in acute or chronic liver injury mouse models. According to the results, we concluded that the biological characteristics of LD-USCs are not affected by basic liver disease. This study provides further evidence of the stem cell characteristics and liver repair function of LD-USCs, which may serve as a theoretical and experimental foundation for autologous USC transplantation technology in the treatment of liver failure and end-stage liver diseases.

Relationship between sarcopenia/myosteatosis and frailty in hospitalized patients with cirrhosis: a sex-stratified analysis

Background:

Previous studies have shown that sarcopenia appears to be a significant contributor to physical frailty among outpatients with cirrhosis. However, the evidence is scant regarding the relationship between sarcopenia and multi-dimensional frailty among inpatients. We aimed to investigate the potential contribution of sarcopenia to frailty in hospitalized patients with cirrhosis in a sex-dependent manner.

Methods:

This cohort enrolled consecutive cirrhotics. Muscle quantity and quality were assessed using the computed tomography-based skeletal muscle index (SMI) and intramuscular adipose tissue content, respectively. Frailty phenotype was clarified by a self-reported Frailty Index. Multiple linear regression determined the association between sarcopenia and frailty phenotype.

Results:

A total of 202 cirrhotic patients with 48.5% male were included. The median Frailty Index was 0.13, rendering 17.3% subjects as frail. Among the 16 frail men, 68.8% had sarcopenia and 62.5% exhibited myosteatosis. In contrast, among the 19 frail women, 26.3% had sarcopenia and 15.8% exhibited myosteatosis. Frail patients had a significantly lower median SMI (42.80 cm²/m²) compared with those with pre-frailty (48.23 cm²/m²) and with robust status (50.82 cm²/m²) in the male but not the female group. In male patients, multivariate linear regression implicated age (β = 0.330, p < 0.001), SMI (β = −0.260, p < 0.001), albumin (β = −0.245, p = 0.005), and sodium (β = −0.179, p = 0.037) as independent risk factors for frailty.

Conclusion:

Sarcopenia is associated with multi-dimensional frailty in male patients with cirrhosis. It is tempting to incorporate sex-specific intervention with the purpose of mitigating frailty among inpatients.

Hospice care for end stage liver disease in the United States

INTRODUCTION

Patients with end-stage liver disease (ESLD) have impaired physical, psychological, and social functions, which can diminish patient quality of life, burden family caregivers, and increase health-care utilization. For those with a life expectancy of less than six months, these impairments and their downstream effects can be addressed effectively through high-quality hospice care, delivered by multidisciplinary teams and focused on the physical, emotional, social, and spiritual wellbeing of patients and caregivers, with a goal of improving quality of life.

AREAS COVERED

In this review, we examine the evidence supporting hospice for ESLD, we compare this evidence to that supporting hospice more broadly, and we identify potential criteria that may be useful in determining hospice appropriateness.

EXPERT OPINION

Despite the potential for hospice to improve care for those at the end of life, it is underutilized for patients with ESLD. Increasing the appropriate utilization of hospice for ESLD requires a better understanding of patient eligibility, which can be based on predictors of high short-term mortality and liver transplant ineligibility. Such hospice criteria should be data-driven and should accommodate the uncertainty faced by patients and physicians.

Assessment of the Frail Patient With End-Stage Liver Disease: A Practical Overview of Sarcopenia, Physical Function, and Disability

Frailty has emerged as a powerful predictor of clinical outcomes (e.g., decompensation, hospitalization, mortality) in patients with end-stage liver disease (ESLD). It is therefore of paramount importance that all patients with ESLD undergo an assessment of frailty, to support life and death decision making (i.e., candidacy for critical care, transplantation) and aid with prioritization of evolving prehabilitation services (i.e., nutrition, physiotherapy, psychotherapy). This article aims to provide a practical overview of the recent advances in the clinical, radiological, and remote assessment tools of the frail patient with ESLD. Historically, clinicians have incorporated an assessment of frailty using the "end-of-the-bed test" or "eyeball test" into their clinical decision making. However, over the last decade, numerous nonspecific and specific tools have emerged. The current evidence supports the use of a combination of simple, user-friendly, objective measures to first identify frailty in ESLD (notably Clinical Frailty Scale, Liver Frailty Index), followed by a combination of serial tools to assess specifically sarcopenia (i.e., muscle ultrasound), physical function (i.e., chair stands, hand grip strength), functional capacity (i.e., 6-minute walk test), and physical disability (i.e., activities of daily living).

Frailty in Nonalcoholic Fatty Liver Cirrhosis: A Comparison with Alcoholic Cirrhosis, Risk Patterns, and Impact on Prognosis

BACKGROUND

Physical frailty increases susceptibility to stressors and predicts adverse outcomes of cirrhosis. Data on disease course in different etiologies are scarce, so we aimed to compare the prevalence and risk factors of frailty and its impact on prognosis in nonalcoholic fatty liver (NAFLD) and alcoholic (ALD) cirrhosis. Patients and Methods. Cirrhosis registry RH7 operates since 2014 and includes hospitalized patients with decompensated cirrhosis, pre-LT evaluation, or curable hepatocellular carcinoma (HCC). From the RH7, we identified 280 ALD and 105 NAFLD patients with at least 6 months of follow-up.

RESULTS

Patients with NAFLD compared with ALD were older and had a higher proportion of females, higher body mass index (BMI) and mid-arm circumference (MAC), lower MELD score, CRP, and lower proportion of refractory ascites. The liver frailty index did not differ, and the prevalence of HCC was higher (17.1 vs. 6.8%, p=0.002). Age, sex, serum albumin, and C-reactive protein (CRP) were independent predictors of frailty. In NAFLD, frailty was also associated with BMI and MAC and in ALD, with the MELD score. The Cox model adjusted for age, sex, MELD, CRP, HCC, and LFI showed that NAFLD patients had higher all-cause mortality (HR = 1.88 95% CI 1.32-2.67, p < 0.001) and were more sensitive to the increase in LFI (HR = 1.51, 95% CI 1.05-2.2).

CONCLUSION

Patients with NAFLD cirrhosis had a comparable prevalence of frailty compared to ALD. Although prognostic indices showed less advanced disease, NAFLD patients were more sensitive to frailty, which reflected their higher overall disease burden and led to higher all-cause mortality.

Tale of the Frail: Understanding Frailty in Cirrhosis

Frailty is a dynamic condition that results in increased vulnerability to health stressors. Often associated with older adults, frailty is not limited to the geriatric population, although aging and disease burden often go hand in hand. This syndrome is recognized increasingly as an important factor in healthcare costs, rate of adverse outcomes, and overall resource utilization. Frailty may be reversible to a degree, and thus appropriate recognition affords a focus for efficient intervention. Notably, frailty is becoming increasingly relevant in cirrhosis, and has been noted to be an independent predictor of outcomes in patients both before and after liver transplantation. Cirrhosis is currently the 12th leading cause of death in the United States, and its incidence is anticipated to markedly increase in the coming years with the aging of our population. With the anticipated surge in disease prevalence, liver disease care will likely shift from specialist-driven to a multidisciplinary approach between primary care physicians, internists, and hepatologists to adequately care for these patients. This review serves as a guide for clinicians to learn about frailty, its role in cirrhosis, and the current tools to educate patients and families about the importance of nutrition and physical exercise within this population.

Recommendations and guidance on nutritional supplementation in the liver transplant setting

Malnutrition is a frequent complication in patients with cirrhosis and liver transplant (LT) candidates. It is highly related to sarcopenia, and their implications in morbidity and mortality go beyond the waiting list period throughout the post-LT. However, there are no specific interventions defined by guidelines, regarding the kind or the timing of the nutritional intervention to improve LT outcomes. Results from studies developed in the LT setting and evaluating their impact on the LT candidates or recipients are discussed in this review, and new research lines are presented.

MELD Score Reflects the Mood, Sleep, and Daily Living Ability in Liver Transplantation Candidates: A Descriptive Study

BACKGROUND This study aimed to assess the psychosocial status (mood, sleep quality, and activities of daily living) of candidates on an orthotopic liver transplantation (OLT) waiting list and to identify the association between psychosocial factors and MELD score in end-stage liver disease (ESLD). MATERIAL AND METHODS Fifty-three OLT waiting list candidates completed 4 scales (Hamilton Rating Scale for Depression [HAMD-17], Hamilton Anxiety Rating Scale [HAM-A], Pittsburgh Sleep Quality Index [PSQI], Activities of Daily Living Scale [ADL]) to assess their affective status, sleep quality, and daily living ability. Candidates were divided into 2 groups, the high MELD score group (MELD score ≥15) and the low MELD score group (MELD score.

Reduced Independence in Daily Living Is Associated with the Gut Microbiome in People with HIV and HCV

Alterations in the gut microbiome are associated with neurocognition and related disorders, including in the context of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection. However, the connection between the gut microbiome and cognitive decline, gauged by increased dependence in instrumental activities of daily living (IADL), remains largely unexplored in the context of these diseases. Here we characterized the gut microbiome using 16S rRNA amplicon sequencing and untargeted metabolomics with liquid chromatography-mass spectrometry from 347 people with HIV, HIV and HCV, or neither, all of whom underwent a comprehensive neuropsychiatric assessment. We observed that IADL-dependent and -independent HIV-monoinfected (HIV-positive [HIV+]/HCV-negative [HCV-]) and coinfected (HIV+/HCV+) individuals have distinct gut microbiomes. Moreover, we found that dependent individuals with HIV or HIV and HCV were enriched in Bacteroides These results may have implications for the characterization of cognitive decline, as well as the development of potential prevention and treatment strategies for individuals infected with HIV and/or HCV. Of particular interest is the possibility that dietary interventions that are known to modify the microbiome could be used to shift the microbiome toward more favorable states for preserving independence.IMPORTANCE The microbes in the gut and the chemicals they produce by metabolism have been linked to brain function. In earlier work, we showed that infection with two viruses, HIV and HCV, changed the gut microbes and metabolism in ways that were associated with a lifetime history of major depressive disorder. Here, we extend this analysis looking at a measurement of independence in daily living. We find that in individuals with HIV, whether or not they also have HCV, those who reported reduced independence were enriched in a genus of bacteria called Bacteroides This result is interesting because Bacteroides is strongly associated with diets low in carbohydrates and high in animal protein, suggesting that diet changes may help preserve independent living in people living long-term with HIV (although clinical intervention trials would be needed in order to confirm this).

Assessing the Time-Dependent Impact of Performance Status on Outcomes After Liver Transplantation

BACKGROUND AND AIMS

Identifying how the prognostic impact of performance status (PS) differs according to indication, era, and time period ("epoch") after liver transplantation (LT) could have implications for selection and treatment of patients on the waitlist. We used national data from the United Kingdom and Ireland to assess impact of PS on mortality separately for HCC and non-HCC recipients.

APPROACH AND RESULTS

We assessed pre-LT PS using the 5-point modified Eastern Cooperative Oncology Group scale and used Cox regression methods to estimate hazard ratios (HRs) that compared posttransplantation mortality in different epochs of follow-up (0-90 days and 90 days to 1 year) and in different eras of transplantation (1995-2005 and 2006-2016). 2107 HCC and 10,693 non-HCC patients were included. One-year survival decreased with worsening PS in non-HCC recipients where 1-year survival was 91.9% (95% confidence interval [CI], 88.3-94.4) in those able to carry out normal activity (PS1) compared to 78.7% (95% CI, 76.7-80.5) in those completely reliant on care (PS5). For HCC patients, these estimates were 89.9% (95% CI, 85.4-93.2) and 83.1% (95% CI, 61.0-93.3), respectively. Reduction in survival in non-HCC patients with poorer PS was in the first 90 days after transplant, with no major effect observed between 90 days and 1 year. Adjustment for donor and recipient characteristics did not change the findings. Comparing era, post-LT mortality improved for HCC (adjusted HR, 0.55; 95% CI, 0.40-0.74) and non-HCC recipients (0.48; 95% CI, 0.42-0.55), but this did not differ according to PS score (P = 0.39 and 0.61, respectively).

CONCLUSIONS

Impact on mortality of the recipient's pretransplant PS is principally limited to the first 3 months after LT. Over time, mortality has improved for both HCC and non-HCC recipients and across the full range of PS.

Patients with Alcoholic Liver Disease Have Worse Functional Status at Time of Liver Transplant Registration and Greater Waitlist and Post-transplant Mortality Which Is Compounded by Older Age

BACKGROUND

Worse functional status correlates with increased mortality on the liver transplant (LT) waitlist. Whether functional status affects LT outcomes equally across cirrhosis etiologies is unclear.

AIMS

We evaluate the impact of functional status on waitlist and post-LT mortality stratified by etiology and age.

METHODS

Functional status among US adults from 2005 to 2017 United Network for Organ Sharing LT registry data was retrospectively evaluated using Karnofsky Performance Status Score (KPS-1 = functional status 80-100%, KPS-2 = 60-70%, KPS-3 = 40-50%, KPS-4 = 10-30%). Waitlist and post-LT survival were stratified by KPS and cirrhosis etiology, including alcoholic liver disease (ALD), nonalcoholic steatohepatitis (NASH), hepatitis C (HCV), and HCV/ALD, and evaluated using Kaplan-Meier and multivariate Cox proportional hazard models.

RESULTS

Among 94,201 waitlist registrants (69.4% men, 39.5% HCV, 26.7% ALD, 23.2% NASH), ALD patients had worse functional status compared to HCV (KPS-4: 17.2% vs. 8.3%, p < 0.001). Worse functional status at time of waitlist registration was associated with higher 90-day waitlist mortality with the greatest effect in ALD (KPS-4 vs. KPS-1: ALD HR 2.16, 95% CI 1.83-2.55; HCV HR 2.17, 95% CI 1.87-2.51). Similar trends occurred in 5-year post-LT survival with ALD patients the most harmed. Compared to patients < 50 years, patients ≥ 65 years had increased waitlist mortality at 90-days if they had HCV or HCV/ALD, and 5-year post-LT mortality regardless of cirrhosis etiology with ALD patients most severely affected.

CONCLUSIONS

In a retrospective cohort study of patients, US ALD patients had disparately worse functional status at time of LT waitlist registration. Worse functional status correlated with higher risk of waitlist and post-LT mortality, affecting ALD and HCV patients the most.

Impact of cancer rehabilitation on the prognosis of patients with hepatocellular carcinoma

Sarcopenia is a prognostic factor for patients with hepatocellular carcinoma (HCC). Cancer rehabilitation (CR) improves patients' physical function and muscle mass. We investigated the effects of CR on the prognosis of patients with HCC. The present study was a prospective observational study, which analyzed 152 patients with HCC who underwent transcatheter arterial chemoembolization (TACE) between 2013 and 2016. Patients were classified into the CR (n=85) and control (n=67) groups. The effects of CR on muscle mass were evaluated by changes in the skeletal muscle index (SMI) before and after TACE. Independent factors associated with survival were evaluated by Cox regression analysis. Kaplan-Meier analysis was used to compare the survival rate between the CR and control groups. The difference in survival rate between the two groups was also examined after propensity score matching. SMI was significantly increased in the CR group compared with the control group. In Cox regression analysis, independent factors associated with survival were CR and Child-Pugh class A (estimate 1.760, 95% CI 0.914–3.226, P=0.001; estimate 1.602, 95% CI 0.426–2.998, P=0.0129). The survival rate was significantly higher in the CR group than in the control group (median 552 vs. 424 days; P=0.0359). The survival rate was also significantly higher in the CR group than that in the control group after propensity score matching (median 529 vs. 369 days; P=0.0332). CR was associated with prolonged survival in patients with HCC who underwent TACE. Patients with cancer are recommended to maintain physical activity even during cancer treatment.

Frailty in liver transplantation: An expert opinion statement from the American Society of Transplantation Liver and Intestinal Community of Practice

Frailty has emerged as a powerful predictor of outcomes in patients with cirrhosis and has inevitably made its way into decision making within liver transplantation. In an effort to harmonize integration of the concept of frailty among transplant centers, the AST and ASTS supported the efforts of our working group to develop this statement from experts in the field. Frailty is a multidimensional construct that represents the end-manifestation of derangements of multiple physiologic systems leading to decreased physiologic reserve and increased vulnerability to health stressors. In hepatology/liver transplantation, investigation of frailty has largely focused on physical frailty, which subsumes the concepts of functional performance, functional capacity, and disability. There was consensus that every liver transplant candidate should be assessed at baseline and longitudinally using a standardized frailty tool, which should guide the intensity and type of nutritional and physical therapy in individual liver transplant candidates. The working group agreed that frailty should not be used as the sole criterion for delisting a patient for liver transplantation, but rather should be considered one of many criteria when evaluating transplant candidacy and suitability. A road map to advance frailty in the clinical and research settings of liver transplantation is presented here.

Current Knowledge, Barriers to Implementation, and Future Directions in Palliative Care for End-Stage Liver Disease

End-stage liver disease (ESLD) is associated with a high degree of morbidity and mortality as well as symptom burden. Despite this, the rate of consultation with palliative care (PC) providers remains low, and invasive procedures near the end of life are commonplace. Studies show that involvement of PC providers improves patient satisfaction, and evidence from other chronic diseases demonstrates reduced costs of care and potentially increased survival. Better integration of PC is imperative but hindered by patient and provider misconceptions about its role in the care of patients with ESLD, specifically among candidates for liver transplantation. Additionally, reimbursement barriers and lack of provider knowledge may contribute to PC underutilization. In this review, we discuss the benefits of PC in ESLD, the variability of its delivery, and key stakeholders' perceptions about its use. Additionally, we identify barriers to more widespread PC adoption and highlight areas for future research.

Frailty and Outcomes After Liver Transplantation

Purpose of review

Frailty is an emerging concept in liver transplantation. We reviewed the literature for the tests of frailty which have been validated to predict outcomes in patients with cirrhosis evaluated for liver transplantation.

Recent findings

Several tools have been developed to further stratify risk of adverse events independent of liver disease severity. These include tests of disability such as activities of daily living and the Karnofsky Performance Score as well as tests of physical frailty such as the Liver Frailty Index (hand-grip, chair stands, and balance).

Summary

Increasingly, the frailty assessment is seen as a critical component of the liver transplant evaluation. Further research is needed to clarify the optimal timing of testing and the implications of longitudinal change.

Physical frailty after liver transplantation

Frailty is prevalent in liver transplant candidates, but little is known of what happens to frailty after liver transplantation. We analyzed data for 214 adult liver transplant recipients who had ≥1 frailty assessment using the Liver Frailty Index (LFI) at 3- (n = 178), 6- (n = 139), or 12- (n = 107) months posttransplant (higher values=more frail). "Frail" and "robust" were defined as LFI ≥4.5 and <3.2. Median pre-liver transplant LFI was 3.7, and was worse at 3 months (3.9; P = .02), similar at 6 months (3.7; P = .07), and improved at 12 months (3.4; P < .001). The percentage who were robust pre- and 3-, 6-, and 12-months posttransplant were 25%, 14%, 28%, and 37%; the percentage frail were 21%, 21%, 10%, and 7%. In univariable analysis, each 0.1 pretransplant LFI point more frail was associated with a decreased odds of being robust at 3- (odds ratio [OR] 0.75), 6- (OR 0.77), and 12-months (OR 0.90) posttransplant (P ≤ .001), which did not change substantially with multivariable adjustment. In conclusion, frailty worsens 3 months posttransplant and improves modestly by 12 months, but fewer than 2 of 5 patients achieve robustness. Pretransplant LFI was a potent predictor of posttransplant robustness. Aggressive interventions aimed at preventing frailty pretransplant are urgently needed to maximize physical health after liver transplantation.

The Liver Frailty Index Improves Mortality Prediction of the Subjective Clinician Assessment in Patients With Cirrhosis

OBJECTIVES

Frailty, a critical determinant of health outcomes, is most commonly assessed in patients with cirrhosis by general clinician assessment that is limited by its subjectivity. We aimed to compare the objective Liver Frailty Index (LFI), consisting of three performance-based tests (grip, chair stands, balance), with a subjective hepatologist assessment.

METHODS

Outpatients with cirrhosis awaiting liver transplantation (LT) underwent: (1) objective measurement using the LFI and (2) subjective clinician assessment. Spearman's correlation assessed associations between the LFI and clinician assessment; Cox regression with waitlist mortality (death/delisting for sickness); discriminative ability with Concordance(C) statistics. The net reclassification index evaluated the percentage of patients correctly reclassified by adding the LFI to the clinician assessment.

RESULTS

Of the 529 patients with cirrhosis, median LFI was 3.8 (range 1.0-7.0) and clinician assessment was 3 (range 0-5). Correlation between LFI and the clinician assessment was modest (ρ=0.38) with high variability by hepatologist (ρ=0.26-0.70). At a median of 11 months, 102 (19%) died/were delisted. Both the LFI (hazard ratio (HR) 2.2, 95% confidence interval (CI) 1.7-2.9) and clinician assessment (HR 1.6, 95% CI 1.3-1.9) were associated with adjusted waitlist mortality risk (P<0.01). The addition of the LFI to the clinician assessment significantly improved mortality prediction over the clinician assessment alone (0.74 vs. 0.68; P=0.02). Compared with the clinician assessment alone, the addition of the LFI correctly reclassified 34% (95% CI 8-53%) of patients to their correct survival status.

CONCLUSION

The subjective clinician assessment can predict waitlist mortality in patients with cirrhosis but is subjective and variable by hepatologist. The addition of the LFI to the subjective clinician assessment significantly improved mortality risk prediction, reclassifying 34% of patients. Our data strongly support the incorporation of the objective LFI to anchor our assessments of patients with cirrhosis to enhance our decision-making.