Role of Nutrition and Muscle in Cirrhosis

A model based on adipose and muscle-related indicators evaluated by CT images for predicting microvascular invasion in HCC patients

BACKGROUND AND AIM

The presence of microvascular invasion (MVI) will impair the surgical outcome of hepatocellular carcinoma (HCC). Adipose and muscle tissues have been confirmed to be associated with the prognosis of HCC. We aimed to develop and validate a nomogram based on adipose and muscle related-variables for preoperative prediction of MVI in HCC.

METHODS

One hundred fifty-eight HCC patients from institution A (training cohort) and 53 HCC patients from institution B (validation cohort) were included, all of whom underwent preoperative CT scan and curative resection with confirmed pathological diagnoses. Least absolute shrinkage and selection operator (LASSO) logistic regression was applied to data dimensionality reduction and screening. Nomogram was constructed based on the independent variables, and evaluated by external validation, calibration curve, receiver operating characteristic (ROC) curve and decision curve analysis (DCA).

RESULTS

Histopathologically identified MVI was found in 101 of 211 patients (47.9%). The preoperative imaging and clinical variables associated with MVI were visceral adipose tissue (VAT) density, intramuscular adipose tissue index (IMATI), skeletal muscle (SM) area, age, tumor size and cirrhosis. Incorporating these 6 factors, the nomogram achieved good concordance index of 0.79 (95%CI: 0.72-0.86) and 0.75 (95%CI: 0.62-0.89) in training and validation cohorts, respectively. In addition, calibration curve exhibited good consistency between predicted and actual MVI probabilities. ROC curve and DCA of the nomogram showed superior performance than that of models only depended on clinical or imaging variables. Based on the nomogram score, patients were divided into high (> 273.8) and low (< = 273.8) risk of MVI presence groups. For patients with high MVI risk, wide-margin resection or anatomical resection could significantly improve the 2-year recurrence free survival.

CONCLUSION

By combining 6 preoperative independently predictive factors of MVI, a nomogram was constructed. This model provides an optimal preoperative estimation of MVI risk in HCC patients, and may help to stratify high-risk individuals and optimize clinical decision making.

Hepatogenous diabetes: Knowledge, evidence, and skepticism

The diabetogenic potential of liver cirrhosis (LC) has been known for a long time, and the name "hepatogenous diabetes" (HD) was coined in 1906 to define the condition. Diabetes mellitus (DM) that develops as a consequence of LC is referred to as HD. In patients with LC, the prevalence rates of HD have been reported to vary from 21% to 57%. The pathophysiological basis of HD seems to involve insulin resistance (IR) and pancreatic β-cell dysfunction. The neurohormonal changes, endotoxemia, and chronic inflammation of LC initially create IR; however, the toxic effects eventually lead to β-cell dysfunction, which marks the transition from impaired glucose tolerance to HD. In addition, a number of factors, including sarcopenia, sarcopenic obesity, gut dysbiosis, and hyperammonemia, have recently been linked to impaired glucose metabolism in LC. DM is associated with complications and poor outcomes in patients with LC, although the individual impact of each type 2 DM and HD is unknown due to a lack of categorization of diabetes in most published research. In fact, there is much skepticism within scientific organizations over the recognition of HD as a separate disease and a consequence of LC. Currently, T2DM and HD are being treated in a similar manner although no standardized guidelines are available. The different pathophysiological basis of HD may have an impact on treatment options. This review article discusses the existence of HD as a distinct entity with high prevalence rates, a strong pathophysiological basis, clinical and therapeutic implications, as well as widespread skepticism and knowledge gaps.

Impact of pretransplant frailty and sarcopenia on the post-transplant prognosis of patients with liver cirrhosis: a systematic review

INTRODUCTION

Frailty and sarcopenia associate with increased mortality in patients with liver cirrhosis on the transplant waitlist. We conducted a systematic review on the impact of pretransplant frailty and sarcopenia on post-transplant outcomes in adult patients with liver cirrhosis.

METHODS

We performed a search in Medline, Embase and Cochrane Central. Of the 12276 references initially recovered, 34 were included.

RESULTS

Frailty and sarcopenia presented a negative impact on post-transplant outcomes and seemed to associate with an overall two-fold reduction in early and 50% reduction in late survival, for severe conditions, according to the largest cohorts. These patients required longer ICU and hospitalization time, had higher rates of sepsis and respiratory complications and lower graft-survival. The reversibility of frailty depended on the severity of functional impairment and on the co-morbidities contributing to frailty. Reversibility of sarcopenia occurred in only a minority of patients, in unbiased studies.

CONCLUSION

Frailty and sarcopenia are double-edged swords: patients with frailty/sarcopenia should be prioritized for liver transplantation due to increased mortality on the waitlist; however, severe frailty/sarcopenia may justify delisting because it associates with dismal prognosis post-liver transplantation. Patients presenting mild to moderate frailty/sarcopenia, should be submitted to liver transplantation before those conditions worsen to a level that significantly impacts post-liver transplantation outcomes.

Automated Measurements of Body Composition in Abdominal CT Scans Using Artificial Intelligence Can Predict Mortality in Patients With Cirrhosis

Body composition measures derived from already available electronic medical records (computed tomography [CT] scans) can have significant value, but automation of measurements is needed for clinical implementation. We sought to use artificial intelligence to develop an automated method to measure body composition and test the algorithm on a clinical cohort to predict mortality. We constructed a deep learning algorithm using Google's DeepLabv3+ on a cohort of de-identified CT scans (n = 12,067). To test for the accuracy and clinical usefulness of the algorithm, we used a unique cohort of prospectively followed patients with cirrhosis (n = 238) who had CT scans performed. To assess model performance, we used the confusion matrix and calculated the mean accuracy of 0.977 ± 0.02 (0.975 ± 0.018 for the training and test sets, respectively). To assess for spatial overlap, we measured the mean intersection over union and mean boundary contour scores and found excellent overlap between the manual and automated methods with mean scores of 0.954 ± 0.030, 0.987 ± 0.009, and 0.948 ± 0.039 (0.983 ± 0.013 for the training and test set, respectively). Using these automated measurements, we found that body composition features were predictive of mortality in patients with cirrhosis. On multivariate analysis, the addition of body composition measures significantly improved prediction of mortality for patients with cirrhosis over Model for End-Stage Liver Disease alone (P < 0.001). Conclusion: The measurement of body composition can be automated using artificial intelligence and add significant value for incidental CTs performed for other clinical indications. This is proof of concept that this methodology could allow for wider implementation into the clinical arena.

The role of recipient myosteatosis in graft and patient survival after deceased donor liver transplantation

BACKGROUND

Myosteatosis is associated with perioperative outcomes in orthotopic liver transplantation (OLT). Here, we investigated the effects of body composition and myosteatosis on long-term graft and patient survival following OLT.

METHODS

Clinical data from 225 consecutive OLT recipients from a prospective database were retrospectively analysed (May 2010 to December 2017). Computed tomography-based lumbar skeletal muscle index (SMI) (muscle mass) and mean skeletal muscle radiation attenuation (SM-RA) (myosteatosis) were calculated using a segmentation tool (3D Slicer). Patients with low skeletal muscle mass (low SMI) and myosteatosis (low SM-RA) were identified using predefined and validated cut-off values.

RESULTS

The mean donor and recipient age was 55 ± 16 and 54 ± 12 years, respectively. Some 67% of the recipients were male. The probability of graft and patient survival was significantly lower in patients with myosteatosis compared with patients with higher SM-RA values (P = 0.011 and P = 0.001, respectively). Low skeletal muscle mass alone was not associated with graft and patient survival (P = 0.273 and P = 0.278, respectively). Dividing the cohort into quartiles, based on the values of SMI and SM-RA, resulted in significant differences in patient but not in graft survival (P = 0.011). Even though multivariable analysis identified low SM-RA as an important prognostic marker (hazard ratio: 2.260, 95% confidence interval: 1.177-4.340, P = 0.014), myosteatosis lost its significance when early mortality (90 days) was excluded from the final multivariable model. Patients with myosteatosis showed significantly higher all-cause mortality and in particular higher rates of deaths due to respiratory and septic complication (P = 0.002, P = 0.022, and P = 0.049, respectively).

CONCLUSIONS

Preoperative myosteatosis may be an important prognostic marker in patients undergoing deceased donor liver transplantation. The prognostic value of myosteatosis seems to be particularly important in the early post-operative phase. Validation in prospective clinical trials is warranted.

Tongue thickness in health vs cirrhosis of the liver: Prospective observational study

BACKGROUND

Malnutrition affects 40%-90% of patients with cirrhosis of the liver. L3 skeletal muscle index (L3SMI) is presently accepted as the most objective and quantitative measure available for sarcopenia, a surrogate marker of malnutrition. L3SMI application is, however, limited by non-availability of computed tomography scanning in remote areas, cost, need for extensive training, and the risk of exposure to radiation. Therefore, an alternative dependable measure with wider availability is needed. Malnutrition causes sarcopenia not only in skeletal muscles but also in other muscular structures such as the psoas muscle, diaphragm and tongue. We therefore hypothesised that the tongue, being easily accessible for inspection and for measurement of thickness using ultrasonography, may be used to document sarcopenia.

AIM

To measure and compare tongue thickness in healthy individuals and in patients with cirrhosis of the liver and to study its correlation with conventional prognostic scores for patients with cirrhosis of the liver.

METHODS

Tongue thickness was measured using ultrasonography. One hundred twenty subjects of either gender aged 18 to 65 years were studied, with 30 subjects in each group. The tongue thickness was compared between groups based on “Child Turcotte Pugh” (CTP) scores. The correlations between measured tongue thickness and “Model for end stage liver disease” (MELD) score and between age and measured tongue thickness were also assessed.

RESULTS

Mean tongue thickness (mean ± SD) in patients with CTP class A, B and C was 4.39 ± 0.39 cm, 4.19 ± 0.53 cm, and 3.87 ± 0.42, respectively, and was 4.33 ± 0.49 cm in normal healthy individuals. Significant differences were seen in tongue thickness between patients with CTP class C and those with CTP class A and B (P < 0.05). Patients with CTP class C also had a significantly reduced tongue thickness than normal individuals (P < 0.05). However, no significant difference was seen in tongue thickness between patients with CTP class A and B and normal individuals. A statistically significant, negative correlation was found between MELD score and tongue thickness (r = -0.331) (P < 0.001). No correlation was observed between L3SMI and MELD score (r = 0.074, P = 0.424). L3SMI (mean ± SD) in healthy subjects was 39.66 ± 6.8 and was 38.26 ± 8.88 in patients with CTP class C, and the difference was not significant. No significant correlation was found between age of the patients and tongue thickness. Intra-class correlation coefficient was used to determine the reliability of the tongue thickness measurements. The intra-class correlation coefficient was 0.984 (95%CI: 0.979-0.989) and was indicative of good reliability.

CONCLUSION

Tongue thickness measured by ultrasonography, correlates significantly with the severity of liver disease, as assessed by CTP and MELD scores. The patients with a CTP score ≥ 10 have significantly reduced tongue thickness as compared to normal individuals and those with less severe liver disease and CTP scores of 5-9. No significant difference in tongue thickness was found between healthy individuals and CTP class A and B patients.

Molecular Mechanism Contributing to Malnutrition and Sarcopenia in Patients with Liver Cirrhosis

Liver cirrhosis is frequently accompanied by disease-related malnutrition (DRM) and sarcopenia, defined as loss of skeletal muscle mass and function. DRM and sarcopenia often coexist in cirrhotic patients and are associated with increased morbidity and mortality. The clinical manifestation of both comorbidities are triggered by multifactorial mechanisms including reduced nutrient and energy intake caused by dietary restrictions, anorexia, neuroendocrine deregulation, olfactory and gustatory deficits. Maldigestion and malabsorption due to small intestinal bacterial overgrowth, pancreatic insufficiency or cholestasis may also contribute to DRM and sarcopenia. Decreased protein synthesis and increased protein degradation is the cornerstone mechanism to muscle loss, among others mediated by disease- and inflammation-mediated metabolic changes, hyperammonemia, increased myostatin and reduced human growth hormone. The concise pathophysiological mechanisms and interactions of DRM and sarcopenia in liver cirrhosis are not completely understood. Furthermore, most knowledge in this field are based on experimental models, but only few data in humans exist. This review summarizes known and proposed molecular mechanisms contributing to malnutrition and sarcopenia in liver cirrhosis and highlights remaining knowledge gaps. Since, in the prevention and treatment of DRM and sarcopenia in cirrhotic patients, more research is needed to identify potential biomarkers for diagnosis and development of targeted therapeutic strategies.

NUTRIC and Modified NUTRIC are Accurate Predictors of Outcome in End-Stage Liver Disease: A Validation in Critically Ill Patients with Liver Cirrhosis

Malnutrition in critically ill patients with cirrhosis is a frequent but often overlooked complication with high prognostic relevance. The Nutrition Risk in Critically ill (NUTRIC) score and its modified variant (mNUTRIC) were established to assess the nutrition risk of intensive care unit patients. Considering the high mortality of cirrhosis in critically ill patients, this study aims to evaluate the discriminative ability of NUTRIC and mNUTRIC to predict outcome. We performed a retro-prospective evaluation in 150 Caucasian cirrhotic patients admitted to our ICU. Comparative prognostic analyses between NUTRIC and mNUTRIC were assessed in 114 patients. On ICU admission, a large proportion of 65% were classified as high NUTRIC (6-10) and 75% were categorized as high mNUTRIC (5-9). High nutritional risk was linked to disease severity and poor outcome. NUTRIC was moderately superior to mNUTRIC in prediction of 28-day mortality (area under curve 0.806 vs. 0.788) as well as 3-month mortality (area under curve 0.839 vs. 0.819). We found a significant association of NUTRIC and mNUTRIC with MELD, CHILD, renal function, interleukin 6 and albumin, but not with body mass index. NUTRIC and mNUTRIC are characterized by high prognostic accuracy in critically ill patients with cirrhosis. NUTRIC revealed a moderate advantage in prognostic ability compared to mNUTRIC.

Serum Zinc Level Grading System: A Useful Model for Composite Hepatic Events in Hepatitis C Virus-Associated Liver Cirrhosis

We aimed to clarify the impact of the serum zinc (Zn) level grading system proposed by the Japanese society of clinical nutrition (JSCN: 80 μg/dL < serum Zn level <130 μg/dL (type A), 60 μg/dL < serum Zn level <80 μg/dL (type B), and serum Zn level <60 μg/dL (type C)) in patients with hepatitis C virus (HCV)-related liver cirrhosis (LC) on the incidence of composite hepatic events (Com-HEs) compared with Child-Pugh (C-P) classification or albumin-bilirubin (ALBI) grade. (n = 275, median age = 67 years). The Akaike information criterion (AIC) was compared among three prognostic models. Factors associated with the incidence of Com-HEs were also studied. The first incidence of any HE was confirmed in 112 patients (40.7%). The AIC value for Com-HEs by the Zn level grading system was the lowest among the three prognostic models (AIC: 301.788 in Zn level grading system, 303.372 in ALBI grade, and 333.953 in C-P classification). In the multivariate analysis, male (p = 0.0031), ALBI grade 3 (p = 0.0041), type B (p = 0.0238), type C (p = 0.0004), and persistent viremia (p < 0.0001) were significant factors associated with the incidence of Com-HEs. In conclusion, the serum Zn level grading system proposed by JSCN can be helpful for estimating the incidence of Com-HEs in HCV-related LC patients.

Phenotypes of Sarcopenic Obesity: Exploring the Effects on Peri-Muscular Fat, the Obesity Paradox, Hormone-Related Responses and the Clinical Implications

Sarcopenic obesity combines the words sarcopenia and obesity. This definition of obesity should be better differentiated between visceral and subcutaneous fat phenotypes. For this reason, this review lays the foundation for defining the subcutaneous and the visceral fat into the context of sarcopenia. Thus, the review aims to explore the missing links on pathogenesis of visceral fat and its relationship on age: defining the peri-muscular fat as a new entity and the subcutaneous fat as a first factor that leads to the obesity paradox. Last but not least, this review underlines and motivates the mechanisms of the hormonal responses and anti-inflammatory adipokines responsible for the clinical implications of sarcopenic visceral obesity, describing factor by factor the multiple axis between the visceral fat-sarcopenia and all mortality outcomes linked to cancer, diabetes, cardiovascular diseases, cirrhosis, polycystic ovary, disability and postoperative complications.

Myosteatosis to predict inferior perioperative outcome in patients undergoing orthotopic liver transplantation

Muscle wasting and alterations of body composition are linked to clinical outcomes in numerous medical conditions. The role of myosteatosis in posttransplant outcomes remains to be determined. Here we investigated skeletal muscle mass and myosteatosis as prognostic factors in patients undergoing orthotopic liver transplantation (OLT). The data of 225 consecutive OLT recipients from a prospective database were retrospectively analyzed (May 2010-December 2017). Computed tomography-based skeletal-muscle-index (muscle mass), visceral-fat-area (visceral adiposity), and mean skeletal-muscle-radiation-attenuation (myosteatosis) were calculated using a segmentation tool. Cut-off values of myosteatosis resulted in a good stratification of patients into low- and high-risk groups in terms of morbidity (Clavien-Dindo ≥3b). Patients with myosteatosis had significantly higher complication rates (90-day Comprehensive Complication Index 68 ± 32 vs 44 ± 30, P < .001) and also displayed significantly longer intensive care (18 ± 25 vs 11 ± 21 days, P < .001) and hospital stay (56 ± 55 vs 33 ± 24 days, P < .001). Estimated costs were 44% higher compared to patients without myosteatosis. Multivariable analysis identified myosteatosis as an independent prognostic factor for major morbidity (odds ratio: 2.772, confidence interval: 1.516-5.066, P = .001). Adding myosteatosis to the well-established Balance-of-Risk-(BAR) score resulted in an increased prognostic value compared to the original BAR score. Myosteatosis may be a useful parameter to predict perioperative outcome in patients undergoing OLT, supporting the role of muscle quality (myosteatosis) over quantity (muscle mass) in this setting.

Body composition predicts mortality and decompensation in compensated cirrhosis patients: A prospective cohort study

Background & Aims

Body composition, particularly sarcopenia, is associated with mortality in patients with decompensated cirrhosis undergoing transplant evaluation. Similar data are limited for non-transplant eligible or compensated patients.

Methods

A total of 274 patients with cirrhosis were followed prospectively for ≤5 years after a CT scan. We utilized Analytic Morphomics® to measure body composition (fat, muscle, and bone) which was rendered into relative values (percentiles) in relation to a reference population. The model for end-stage liver disease (MELD) score was used as a reference model for survival prediction. We validated our models in a separate cohort.

Results

Our cohort had a mean Child-Pugh score of 7.0 and a mean MELD of 11.3. The median follow-up time was 5.05 years. The proportion of patients alive at 1, 3 and 5 years was 86.5%, 68.0%, and 54.3%; 13 (4.6%) underwent liver transplantation. Child-Pugh B/C (vs. A) cirrhosis was associated with decreased muscle, subcutaneous, and visceral fat area but increased subcutaneous/visceral fat density. Decreased normal density muscle mass was associated with mortality (hazard ratio [HR] 0.984, p <0.001) as well as visceral and subcutaneous fat density (HR 1.013 and 1.014, respectively, p <0.001). Models utilizing these features outperformed MELD alone for mortality discrimination in both the derivation and validation cohort, particularly for those with compensated cirrhosis (C-statistics of 0.74 vs. 0.58). Using competing risk analysis, we found that subcutaneous fat density was most predictive of decompensation (subdistribution HR 1.018, p = 0.0001).

Conclusion

The addition of body composition features to predictive models improves the prospective determination of prognosis in patients with cirrhosis, particularly those with compensated disease. Fat density, a novel feature, is associated with the risk of decompensation.

Lay summary

Am I at high risk of getting sicker and dying? This is the key question on the mind of patients with cirrhosis. The problem is that we have very few tools to help guide our patients, particularly if they have early cirrhosis (without symptoms like confusion or fluid in the belly). We found that how much muscle and fat the patient has and what that muscle or fat looks like on a CT scan provide helpful information. This is important because many patients have CT scans and this information is hiding in plain sight.

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Features of body composition can predict clinical outcomes in patients with cirrhosis awaiting liver transplantation.

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Data are lacking regarding long-term outcomes among patients with compensated disease.

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We show that features of muscle and fat are associated with decompensation and risk of death across the spectrum of cirrhosis.

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CT scans obtained for unrelated clinical purposes can be analyzed as a digital risk biomarker for patients with compensated cirrhosis.

Combined albumin-bilirubin grade and Mac-2 binding protein glycosylation isomer as a useful predictor in compensated liver cirrhosis

We aimed to compare the impact on survival among albumin-bilirubin (ALBI) grade, modified ALBI (mALBI) and our proposed combined ALBI grade and Mac-2 binding protein glycosylation isomer (M2BPGi) or FIB4 index grading system in chronic hepatitis C (CHC) related compensated liver cirrhosis (n = 165, 93 men and 72 women, median age = 67 years). Patients with ALBI grade 1, 2, and 3 were allocated a score of 1, 2, and 3 points, respectively. Patients with mALBI grade 1, 2A, and 2B were allocated a score of 1, 2, and 3 points, respectively. Patients with a high or low M2BPGi were allocated a score of 1 and 0 point. Patients with a high or low FIB4 index were allocated a score of 1 and 0 point. Sum of the point of ALBI (1, 2, or 3) and M2BPGi (0 or 1) or FIB4 index (0 or 1) was defined as ALBI-M2BPGi grade or ALBI-FIB4 grade. Prognostic accuracy was compared using the Akaike information criterion (AIC) value and time dependent receiver operating characteristics (ROC) curve analysis. The median follow-up duration was 5.422 years. AIC value for survival by ALBI-M2BPGi grade was the lowest among 4 prognostic models (AIC: 205.731 in ALBI grade, 200.913 in mALBI grade, 189.816 in ALBI-M2BPGi grade, and 204.671 in ALBI-FIB4 grade). All area under the ROC curves of ALBI-M2BPGi grade in each time point were higher than those of ALBI grade, mALBI grade, and ALBI-FIB4 grade. In conclusion, our proposed ALBI-M2BPGi grading system seems to be helpful for estimating prognosis in patients with CHC related compensated LC.

Serum Zinc Level Classification System: Usefulness in Patients with Liver Cirrhosis

Currently, the Japanese society of clinical nutrition (JSCN) defines serum zinc (Zn) level < 60 μg/dL as Zn deficiency and 60 μg/dL ≤ serum Zn level < 80 μg/dL as subclinical Zn deficiency, and 80 μg/dL ≤ serum Zn level < 130 μg/dL as normal Zn range. We aimed to elucidate the prognostic impact of this Zn classification system in patients with liver cirrhosis (LC) compared to the Child–Pugh classification and the albumin–bilirubin (ALBI) grading system (n = 441, median age = 66 years). The Akaike information criterion (AIC) with each evaluation method was tested in order to compare the overall survival (OS). The median serum Zn level was 65 μg/dL. There were 56 patients with normal Zn level, 227 with subclinical Zn deficiency and 158 with Zn deficiency. OS was well stratified among three groups of serum Zn level (p < 0.0001). The AIC value for survival by the Zn classification system was the lowest among three prognostic models (AIC: 518.99 in the Child–Pugh classification, 502.411 in ALBI grade and 482.762 in the Zn classification system). Multivariate analyses of factors associated with OS revealed that serum Zn classification by JSCN was an independent factor. In conclusion, the serum Zn classification proposed by JSCN appears to be helpful for estimating prognosis in LC patients.

Muscle psoas indices measured by ultrasound in cirrhosis - Preliminary evaluation of sarcopenia assessment and prediction of liver decompensation and mortality

BACKGROUND

No data on the European population exists regarding the use of an ultrasoundbased measurement of psoas diameter for sarcopenia assessment in cirrhosis.

AIMS

To determine the applicability of an ultrasound measurement of the psoas muscle diameter in patients with decompensated liver cirrhosis and to assess whether this surrogate is associated with hospitalization due to decompensation and mortality.

METHODS

In 75 consecutive patients with decompensated liver cirrhosis and in 20 control subjects (January 2016 to November 2017), psoas muscle diameter was prospectively measured. The reliable measurements were used for the further analysis. Relevant clinical and laboratory data was collected.

RESULTS

Ultrasound measurement was applicable in 100% of control and in 72% of study subjects. Psoas to height ratio was significantly related to hospitalization and mortality (p < 0.0001, HR 0.717, 95% CI: 0.622-0.828 and p = 0.022; HR = 0.825, 95% CI: 0.701-0.973) as was psoas muscle index (p < 0.0001, HR = 0.881, 95% CI: 0.836-0.929 and p = 0.017; HR = 0.930, 95% CI: 0.876-0.987).

CONCLUSIONS

Ultrasound measurement of psoas muscle diameter and its derived indices is applicable and associated with hospitalization and mortality in patients with decompensated liver cirrhosis.

Dietary total antioxidant capacity is positively associated with muscular strength in cirrhotic outpatients: a cross-sectional study

BACKGROUND

Cirrhosis is the end-stage of progressive fibrosis, in which oxidative stress and inflammation-related pathways can modulate the cellular and tissue events involved in the pathogenesis of liver fibrosis. Dietary intake of antioxidants has been suggested to protect against oxidative damage and related clinical complications. The present study aimed to investigate the potential association of the dietary total antioxidant capacity (dTAC) with anthropometric, functional and biochemical markers, as well as the severity of the disease, in cirrhotic outpatients.

METHODS

Sixty-two outpatients (38 men and 24 women) with a mean (SD) age of 59.1 (9.9) years were evaluated. Dietary TAC was estimated from a food frequency questionnaire. Aetiology and severity of liver cirrhosis, lifestyle characteristics, occurrence of comorbidities and oedema, and anthropometric, functional and biochemical markers were all assessed.

RESULTS

Cirrhotic outpatients with higher dTAC also had higher values of the hand-grip strength (P = 0.029) and arm muscle area (P = 0.027). After adjusting by sex, age, smoking and alcohol intake, the addition of 1 mmol day^-1 of dTAC contributed to increase 0.552 kg f^-1 in hand-grip strength (P < 0.05). The addition of one mmol day^-1 of dTAC contributed to an arm muscle area increase 0.565 cm² (P < 0.05) on average.

CONCLUSIONS

The dTAC was positively associated with hand-grip strength and arm muscle area in cirrhotic outpatients. The implications of the present study are important in clinical practice because a diet rich in antioxidants may be an ally in the control of excessive reactive oxygen species production in cirrhotic outpatients with repercussion on muscle mass and strength.

The Relationship of Obesity, Nutritional Status and Muscle Wasting in Patients Assessed for Liver Transplantation

INTRODUCTION

Obesity co-exists with malnutrition and muscle atrophy in patients with cirrhosis. Muscle wasting is a feature of sarcopenia, a known determinant of patient outcomes. This is the first description of a relationship between obesity, subjective global assessment (SGA) of nutritional status and muscle wasting in patients with cirrhosis.

METHODS

The relationship between body mass index (BMI with obesity defined as ≥ 30 kg/m2), nutritional status (assessed by liver-specific subjective global assessment-SGA) and muscle wasting (assessed by corrected total cross-sectional psoas muscle area-cTPA) was analysed in patients with cirrhosis considered for liver transplantation between 1 January 2012 and 31 December 2014.

RESULTS

There were 205 patients, of whom 70% were males. The mean age was 52 ± 0.7 years and the Model for End-Stage Liver Disease (MELD) score was 16.8 ± 0.5. Overall, 31% of patients were obese and 56% of well-nourished (SGA A) individuals were obese. Muscle wasting was identified in 86% of all patients, irrespective of their nutritional status (A, B, C). All obese males classified as well-nourished (SGA A) were sarcopenic and 62% of obese females classified as SGA A were sarcopenic. Muscle wasting was worse in obese individuals (cTPA 230.9 mm2/m2 ± 12.9, p < 0.0001) and more likely to be associated with hepatic encephalopathy (p = 0.03). Univariate and multivariate analysis demonstrated testosterone deficiency was significantly associated with muscle wasting (p = 0.007) but not obesity (p = 0.8).

CONCLUSION

Obesity combined with muscle wasting is common in patients with cirrhosis. Muscle wasting is common in well-nourished (SGA A) obese patients. Consequently, all patients assessed for liver transplantation should undergo additional screening for malnutrition and muscle wasting irrespective of BMI.

Nutritional support in cirrhotic patients with sarcopenia

Sarcopenia has been linked to oncologic and chronic diseases such as liver cirrhosis. In fact, sarcopenia is present in 25-70% of patients with liver cirrhosis. Furthermore, sarcopenia is an independent predictor of poor prognosis in many diseases. Currently cirrhotic patients are recommended to adopt a high protein diet (1.5 g/kg/day) with 30-40 kcal/kg/day and several meals throughout the day, being late evening snack intake with at least 50 g of carbohydrates of special importance. Despite the growing interest in the impact of sarcopenia in cirrhotic patients, there are still gaps in knowledge in the appropriate diagnostic criteria for this syndrome, the role of gut microbiota, as well as the most appropriate nutritional therapy.

Combined Albumin-Bilirubin Grade and Skeletal Muscle Mass as a Predictor in Liver Cirrhosis

We aimed to compare the prognostic impact among albumin-bilirubin (ALBI) grade, the Child-Pugh classification and our proposed combined ALBI grade and skeletal muscle mass (SMM) grading system in patients with liver cirrhosis (LC) (n = 468, 254 males and 214 females) using the Akaike information criterion (AIC) and time-dependent receiver operating characteristics (ROC) curve analysis. SMM was tested using bioimpedance analysis. Male subjects with skeletal muscle mass index (SMI) <7.0 cm²/m² and female subjects with SMI <5.7 cm²/m² were defined as having low SMM. Patients with ALBI grade 1, 2 and 3 were given 1, 2 and 3 points. Patients with and without low SMM were given 1 and 0 point, respectively. The sum of the point of ALBI (1, 2, or 3) and SMM (0 or 1) was defined as the ALBI-SMM grade. The value obtained with the AIC for survival by the ALBI-SMM grade was the lowest among three assessment methods (AIC: 513.418 in ALBI grade, 533.584 in Child-Pugh classification and 493.72 in ALBI-SMM grade). In time-dependent ROC analysis, all area under the ROCs of the ALBI-SMM grade in each time point were the highest among three assessment methods. In conclusion, the ALBI-SMM grading system can be helpful for LC patients.

Continuous terlipressin infusion is associated with improved diet intake and muscle strength in patients awaiting liver transplant

Background & Aims

Portal hypertension contributes to the pathogenesis of malnutrition and sarcopenia in cirrhosis via multiple mechanisms. Terlipressin is a vasopressin analogue that we administer via continuous outpatient infusion, as a bridge to transplantation in patients with hepatorenal syndrome or refractory ascites. We describe, for the first time, the impact of outpatient terlipressin on nutritional and muscle parameters.

Methods

Nutrition (subjective global assessment), handgrip strength, dietary intake (energy, protein), frequency of paracentesis and severity of liver disease (model for end-stage liver disease score) were prospectively recorded at terlipressin commencement and follow-up (transplantation, cessation or census date).

Results

Nineteen patients were included (89% male, median age 59.6 years, median model for end-stage liver disease score 24), of whom 12 had hepatorenal syndrome and 7 had refractory ascites. All patients were malnourished at baseline, 63% (n = 12) had sarcopenic-range grip strength, and mean paracentesis frequency was 2.86 ± 1.62/month. Median duration of terlipressin was 51 days (interquartile range 29–222). Fourteen patients (74%) were transplanted, 2 delisted (10%) and 3 (16%) continued terlipressin. Energy and protein intake improved significantly following terlipressin, from 17.94 ± 5.43 kcal/kg to 27.70 ± 7.48 kcal/kg, and 0.74 ± 0.28 g/kg to 1.16 ± 0.31 g/kg, respectively (both p < 0.001). Handgrip strength increased from 25.36 ± 8.13 kg to 28.49 ± 7.63 kg (p = 0.001). Linear regression analysis demonstrated hand grip strength increased 0.075% for every 1-day of terlipressin (p = 0.005). The frequency of large-volume paracentesis reduced by 46%, to 1.57 ± 1.51/month (p = 0.001).

Conclusion

Continuous terlipressin infusion reduces the complications of portal hypertension and is associated with an improvement in nutritional and muscle parameters in patients on the liver transplant waiting list, in whom such characteristics usually demonstrate progressive decline. This validates both the aetiological role of portal hypertension in malnutrition and represents a promising new anabolic therapy.

Lay summary

Malnutrition and poor muscle strength are common in liver disease and often get worse while patients await liver transplant. Terlipressin is a medication used to treat portal hypertension in patients with hepatorenal syndrome. It is usually given for a few days or weeks in patients confined to hospital. Our centre provides outpatient terlipressin for weeks to months as a bridge to liver transplant. In patients treated with terlipressin at our hospital, we observed a substantial increase in their dietary intake and muscle strength, which may improve their quality of life and outcomes after liver transplant.

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Malnutrition and poor muscle strength are highly prevalent in cirrhotics with hepatorenal syndrome.

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Terlipressin infusion increased energy and protein intake in patients with hepatorenal syndrome.

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Handgrip strength continued to increase with every day of terlipressin therapy

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Medium to long-term terlipressin infusion was safe and efficacious as a bridge to liver transplant.

Emerging awareness on the importance of skeletal muscle in liver diseases: time to dig deeper into mechanisms!

Skeletal muscle is a tissue that represents 30–40% of total body mass in healthy humans and contains up to 75% of total body proteins. It is thus the largest organ in non-obese subjects. The past few years have seen increasing awareness of the prognostic value of appreciating changes in skeletal muscle compartment in various chronic diseases. Hence, a low muscle mass, a low muscle function and muscle fatty infiltration are linked with poor outcomes in many pathological conditions. In particular, an affluent body of evidence links the severity, the complications and mortality of chronic liver disease (CLD) with skeletal muscle depletion. Yet it is still not clear whether low muscle mass is a cause, an aggravating factor, a consequence of the ongoing disease, or an epiphenomenon reflecting general alteration in the critically ill patient. The mechanisms by which the muscle compartment influences disease prognosis are still largely unknown. In addition, whether muscle alterations contribute to liver disease progression is an unanswered question. Here, we first review basic knowledge about muscle compartment to draw a conceptual framework for interpreting skeletal muscle alteration in CLD. We next describe recent literature on muscle wasting in cirrhosis and liver transplantation. We then discuss the implication of skeletal muscle compartment in non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH), focusing on plausible metabolic disruption in muscle compartment that might participate in NAFLD progression. Finally, we discuss shortcomings and challenges we need to address in the near future prior to designate the muscle compartment as a therapeutic target in CLD.

Impact of pre-sarcopenia in sorafenib treatment for advanced hepatocellular carcinoma

Background

The present study aimed to investigate the impact of pre-sarcopenia on the prognosis of patients with advanced hepatocellular carcinoma (HCC) treated with sorafenib.

Methods

We enrolled 214 patients (71 ± 10 years old; 166 men and 48 women; 90% Child–Pugh grade A and 10% Child–Pugh grade B) treated with sorafenib in our hospital from July 2009 to August 2016. The muscle volume was measured from CT images just before sorafenib administration using software (SliceOmatic). Skeletal muscle mass index was calculated, and the presence of pre-sarcopenia was judged according to the standard (42 cm²/m² for men and 38 cm²/m² for women) proposed by the Japan Society of Hepatology.

Results

Pre-sarcopenia was found in 123 patients (57%). The overall survival (OS) in patients with pre-sarcopenia tended to be worse than in patients without pre-sarcopenia (median 252 vs. 284 days, respectively; p = 0.16). Multivariate Cox hazard analysis revealed a baseline serum albumin level of ≤3.5 g/dl [hazard ratio (HR) 1.9; p = 0.0006], a baseline alpha-fetoprotein(AFP) level of ≥100 ng/ml (HR 2.1; p = 0.002), presence of lesions in bilateral hepatic lobes (HR 1.7; p = 0.03), and presence of major portal vein invasion (HR 1.8; p = 0.01) to be independent prognostic factors. In the 68 patients who had three or more negative prognostic factors, the presence of pre-sarcopenia did not correlate with prognosis. Of the 146 patients who had two or less prognostic factors, OS was significantly worse in 84 patients (58%) with pre-sarcopenia than in 62 patients without pre-sarcopenia (median 417 vs. 562 days, respectively; p = 0.047), and Cox hazard analysis revealed pre-sarcopenia to be an important prognostic factor (HR 1.6; p = 0.047).

Conclusion

In sorafenib treatment for advanced HCC, pre-sarcopenia is a significant prognostic factor in patients with two or less negative prognostic factors, and could be the target of intervention to improve prognosis.

Fat-free muscle mass in magnetic resonance imaging predicts acute-on-chronic liver failure and survival in decompensated cirrhosis

Muscle mass seems to be a prognostic marker in patients with liver cirrhosis. However, reported methods to quantify muscle mass are heterogeneous, consented cutoff values are missing, and most studies have used computed tomography. This study evaluated fat-free muscle area (FFMA) as a marker of sarcopenia using magnetic resonance imaging (MRI) in patients with decompensated cirrhosis with transjugular intrahepatic portosystemic shunt (TIPS). The total erector spinae muscle area and the intramuscular fat tissue area were measured and subtracted to calculate the FFMA in 116 patients with cirrhosis by TIPS and MRI. The training cohort of 71 patients compared computed tomography-measured transversal psoas muscle thickness with FFMA. In 15 patients MRI was performed before and after TIPS, and in 12 patients follistatin serum measurements were carried out. The results on FFMA were confirmed in a validation cohort of 45 patients. FFMA correlated with follistatin and transversal psoas muscle thickness and showed slightly better association with survival than transversal psoas muscle thickness. Gender-specific cutoff values for FFMA were determined for sarcopenia. Decompensation (ascites, overt hepatic encephalopathy) persisted after TIPS in the sarcopenia group but resolved in the nonsarcopenia group. Sarcopenic patients showed no clinical improvement after TIPS as well as higher mortality, mainly due to development of acute-on-chronic liver failure. FFMA was an independent predictor of survival in these patients.

CONCLUSION

This study offers an easy-to-apply MRI-based measurement of fat-free muscle mass as a marker of sarcopenia in decompensated patients; while TIPS might improve sarcopenia and thereby survival, persistence of sarcopenia after TIPS is associated with a reduced response to TIPS and a higher risk of acute-on-chronic liver failure development and mortality. (Hepatology 2018;67:1014-1026).

Interventions to improve physical function and prevent adverse events in cirrhosis

Cirrhosis is associated with debilitating complications that significantly impact on a patient’s physical function and reduce quality of life. Owing to highly prevalent sarcopenia, malnutrition and hepatic encephalopathy, functional impairment or frailty is a common complication of cirrhosis. Frailty in turn increases the patient’s risk of hospitalization, accidental falls and fractures, and death. The management of frailty and its associated adverse effects is imperative in improving the overall prognosis of patients with advanced liver disease. The cornerstone of therapy revolves around optimizing physical function with appropriate nutrition and exercise. Nutritional therapy with protein supplementation has shown significant benefit, while studies on exercise have been controversial. However, newly emerging studies trend towards a beneficial effect of physical exercise with improvement in quality of life. The implementation of technology in liver disease management shows future promise. Fitbits and other wearable devices can be used to help monitor a patient’s personal progress in physical exercise and nutritional optimization. Additionally, the progressive development of new smartphone applications to help aid in the diagnosis and monitoring of complications of cirrhosis provides a sophisticated avenue for improving care of patients with cirrhosis.

Usefulness of Simplified Nutritional Appetite Questionnaire (SNAQ) in Appetite Assessment in Elder Patients with Liver Cirrhosis

BACKGROUND

Appetite has received little attention in health care and researches in liver cirrhosis. The Simplified Nutritional Appetite Questionnaire (SNAQ), a self-assessment nutritional screening tool, could be used to screen the risk of malnutrition and weight loss. Our objective was to assess the usefulness of SNAQ in appetite assessment in patients with liver cirrhosis.

METHODS

Seventy patients were enrolled. Appetite assessment was applied in the enrolled patients by completing SNAQ. Weight, hemoglobin, albumin, pro-albumin and Child-Pugh class were evaluated and recorded. The correlation between SNAQ score and these indexes was also evaluated. The most discriminating SNAQ value was calculated, which separated the participant at risk of weight loss.

RESULTS

In participants with SNAQ < 14, the BMI, hemoglobin, albumin and pro-albumin were significantly less than those in participants with SNAQ ≥ 14. The correlation between SNAQ and these indexes were also observed (hemoglobin: r = 0.334, p = 0.005; albumin: r = 0.384, p = 0.001; pro-albumin: r = 0.342, p = 0.004; BMI: r = 0.550, p = 0.000). The SNAQ scores reduced along with the increase of Child-Pugh class. An SNAQ score under 11.5 was the best clinical indicator of elder people at risk of weight loss.

CONCLUSIONS

SNAQ can be used to evaluate the appetite loss and predicting the weight loss in patients with liver cirrhosis. The SNAQ tool also can be used by clinicians and nurses to identify patients with a poor appetite who are at risk of weight loss.

Sarcopenia in Liver Disease: Current Evidence and Issues to Be sResolved

Sarcopenia is a common clinical symptom in aging and patients with wasting diseases, characterized by a decreased skeletal muscle mass. As a consequence of lifestyle change, the nonalcoholic fatty liver disease (NAFLD) presents a rising trend. In the past three decades, increasing evidence has proved that sarcopenia is related to NAFLD. In this chapter, we will summarize the emerging evidence of the predictive role of sarcopenia in NAFLD and review the diagnosis value, feasible mechanism, and therapy strategies of sarcopenia in NAFLD. Sarcopenia is a potential risk factor for NAFLD, and targeting sarcopenia can benefit NAFLD to some extent.

Nutrition and Muscle in Cirrhosis

As the cirrhosis progresses, development of complication like ascites, hepatic encephalopathy, variceal bleeding, kidney dysfunction, and hepatocellular carcinoma signify increasing risk of short term mortality. Malnutrition and muscle wasting (sarcopenia) is yet other complications that negatively impact survival, quality of life, and response to stressors, such as infection and surgery in patients with cirrhosis. Conventionally, these are not routinely looked for, because nutritional assessment can be a difficult especially if there is associated fluid retention and/or obesity. Patients with cirrhosis may have a combination of loss of skeletal muscle and gain of adipose tissue, culminating in the condition of "sarcopenic obesity." Sarcopenia in cirrhotic patients has been associated with increased mortality, sepsis complications, hyperammonemia, overt hepatic encephalopathy, and increased length of stay after liver transplantation. Assessment of muscles with cross-sectional imaging studies has become an attractive index of nutritional status evaluation in cirrhosis, as sarcopenia, the major component of malnutrition, is primarily responsible for the adverse clinical consequences seen in patients with liver disease. Cirrhosis is a state of accelerated starvation, with increased gluconeogenesis that requires amino acid diversion from other metabolic functions. Protein homeostasis is disturbed in cirrhosis due to several factors such as hyperammonemia, hormonal, and cytokine abnormalities, physical inactivity and direct effects of ethanol and its metabolites. New approaches to manage sarcopenia are being evolved. Branched chain amino acid supplementation, Myostatin inhibitors, and mitochondrial protective agents are currently in various stages of evaluation in preclinical studies to prevent and reverse sarcopenia, in cirrhosis.

The impact of nutrition on quality of life of patients with hepatitis C

PURPOSE OF REVIEW

The aim of this study was to review the most recent aspects of nutrition and its impact on health-related quality of life (HRQOL) in patients with chronic hepatitis C (CHC).

RECENT FINDINGS

Low HRQOL scores have been found in all stages of hepatitis C virus (HCV) infection. Of the factors linked to HRQOL, three aspects should be emphasized, nutritional status, physical activity and mental health status. Regarding the nutrition and metabolic conditions, a broad spectrum of nutritional disorders may impact on HRQOL of patients with CHC.

SUMMARY

Malnutrition, which is a significant comorbidity in end-stage of all chronic liver diseases, has been recognized as a significant factor related to poor HRQOL. Of note, in individuals chronically infected with HCV, low muscle skeletal mass, an early indicator of undernourishment, precedes the development of cirrhosis. Because of the strict linkage between HRQOL, nutrition and physical activity, the assessment of the musculoskeletal system abnormalities in every patient with CHC, independently of the stage of the liver disease, is of utmost relevance. Maintenance of healthy skeletal muscle is essential to reduce the negative effects of sarcopenia on HRQOL. Otherwise, overweight/obesity and chronic HCV infection can cause insulin resistance, which has been associated with HRQOL impairment.

A Comprehensive Review of Bioelectrical Impedance Analysis and Other Methods in the Assessment of Nutritional Status in Patients with Liver Cirrhosis

It is assumed that approximately 24–66% of patients with liver cirrhosis develop malnutrition. Numerous pathological processes lead to serious disorders of nutritional status in this group of patients. Malnutrition in the course of liver cirrhosis is associated with increased morbidity, complications, and low quality of life. Under these conditions, detection of malnutrition is of crucial importance. This review explores the complex mechanisms that lead to malnutrition in the course of liver cirrhosis and focuses on methods used in the assessment of nutritional status in cirrhotic patients. Among others, the role of bioelectrical impedance is highlighted. This noninvasive tool is promising and quite an accurate method of estimating body composition.

Clinical utility of bioimpedance analysis in liver cirrhosis

BACKGROUND

The objective of the present study was to examine the impact of muscle mass depletion (MMD) as determined by data in bioimpedance analysis (BIA) in liver cirrhosis (LC) patients (n = 382, 204 in male and 178 in female) on survival and to validate the utility of cutoff values in BIA recommended from current recommendations.

METHODS

Muscle mass depletion was defined as patients with skeletal muscle mass index (SMI) using BIA <7.0 cm² /m² for male and <5.7 cm² /m² for female based on current recommendations. We retrospectively examined variables related to the presence of MMD using univariate and multivariate analyses and investigated the impact of MMD on survival.

RESULTS

A total of 135 patients (35.3%) had MMD. Subjects were predominantly Child-Pugh A (278/382, 72.8%). For the entire cohort, the 5-year cumulative survival rates were 59.8% in patients with MMD and 84.4% in patients without MMD (P < 0.0001). In the multivariate analysis for survival, MMD revealed to be a significant adverse predictor for survival and for most subgroup analyses, the differences between MMD group and non-MMD group in terms of survival reached significance.

CONCLUSION

Muscle mass measurement using BIA may be helpful for LC patients and current recommendations were well verified in our analysis.

Symptom Domain Groups of the Patient-Reported Outcomes Measurement Information System Tools Independently Predict Hospitalizations and Re-hospitalizations in Cirrhosis

BACKGROUND

Patient-Reported Outcomes Measurement Information System (PROMIS) tools can identify health-related quality of life (HRQOL) domains that could differentially affect disease progression. Cirrhotics are highly prone to hospitalizations and re-hospitalizations, but the current clinical prognostic models may be insufficient, and thus studying the contribution of individual HRQOL domains could improve prognostication.

AIM

Analyze the impact of individual HRQOL PROMIS domains in predicting time to all non-elective hospitalizations and re-hospitalizations in cirrhosis.

METHODS

Outpatient cirrhotics were administered PROMIS computerized tools. The first non-elective hospitalization and subsequent re-hospitalizations after enrollment were recorded. Individual PROMIS domains significantly contributing toward these outcomes were generated using principal component analysis. Factor analysis revealed three major PROMIS domain groups: daily function (fatigue, physical function, social roles/activities and sleep issues), mood (anxiety, anger, and depression), and pain (pain behavior/impact) accounted for 77% of the variability. Cox proportional hazards regression modeling was used for these groups to evaluate time to first hospitalization and re-hospitalization.

RESULTS

A total of 286 patients [57 years, MELD 13, 67% men, 40% hepatic encephalopathy (HE)] were enrolled. Patients were followed at 6-month (mth) intervals for a median of 38 mths (IQR 22-47), during which 31% were hospitalized [median IQR mths 12.5 (3-27)] and 12% were re-hospitalized [10.5 mths (3-28)]. Time to first hospitalization was predicted by HE, HR 1.5 (CI 1.01-2.5, p = 0.04) and daily function PROMIS group HR 1.4 (CI 1.1-1.8, p = 0.01), independently. In contrast, the pain PROMIS group were predictive of the time to re-hospitalization HR 1.6 (CI 1.1-2.3, p = 0.03) as was HE, HR 2.1 (CI 1.1-4.3, p = 0.03).

CONCLUSIONS

Daily function and pain HRQOL domain groups using PROMIS tools independently predict hospitalizations and re-hospitalizations in cirrhotic patients.

Handgrip Strength as an Important Bed Side Tool to Assess Malnutrition in Patient with Liver Disease

BACKGROUND

Malnutrition is frequently present in patients with cirrhosis. Anthropometric measures such as body mass index (BMI), mid arm muscle circumference (MAMC), triceps skin fold thickness (TST) and subjective global assessment (SGA) have some limitations in assessment of malnutrition. This study aims to determine the prevalence of malnutrition in non-hospitalized cirrhotic and chronic hepatitis patients and to assess handgrip (HG) strength as a tool for identifying malnutrition.

METHODS

Consecutive patients of cirrhosis (n = 352), chronic hepatitis (n = 189) and healthy controls (n = 159) were enrolled. All patients underwent MAMC, TST, HG and SGA assessment. Malnutrition was diagnosed on basis of SGA score. Values of MAMC, TST and HG below the 5th percentile or less than 60% of healthy controls were considered as abnormal.

RESULTS

According to SGA (taken as standard) 24% patients with chronic hepatitis and 56% of patients with cirrhosis had malnutrition (P = 0.001). In patients with chronic hepatitis prevalence of malnutrition according to MAMC (12%), TST (31%) and HG (18%). In patients with cirrhosis prevalence of malnutrition according to MAMC (27%), TST (60%) and HG (42%). HG exercise strength had the highest area under curve 0.82 (95% confidence interval (CI) 0.78-0.86, P = 0.001) compared to MAMC 0.60 (95% CI 0.55-0.64, P = 0.001) and TST 0.65 (95% CI 0.61-0.69, P = 0.001) for assessing malnutrition. On comparison of HG, TST and MAMC, the sensitivity was 67%, 60% and 31%, respectively, Specificity was 95%, 71% and 89%, respectively, and diagnostic accuracy was 87%, 67% and 71%, respectively.

CONCLUSION

HG strength is an excellent tool to assess at bed side the nutrition status in patients with cirrhosis and has the highest diagnostic accuracy compared to other anthropometric tests such as MAMC and TST.

Wuweizi protects against liver cirrhosis by promoting endogenous stem cell proliferation

AIM: To investigate the mechanism for Wuweizi to treat liver cirrhosis.

METHODS: A rat model of liver cirrhosis was developed with CCl₄. Rats were randomly divided into five groups: three treatment groups [small dose Wuweizi group (A1), middle dose group (A2) and high dose group (A3)], a blank group (C) and a model group (M). Except group C, liver cirrhosis was induced in all other groups. Groups A1, A2 and A3 were given 1.0, 1.5 and 2.0 mg/200 g Wuweizi, respectively. After treatment, histopathology, liver function [aspartate transaminase (AST), alanine transaminase (ALT) and albumin (ALB)], hepatic fibrosis, stem cell proliferation, and the expression ofCK-18, ALB and α-fetoprotein (AFP) were assessed.

RESULTS: In the treatment groups, there was an improvement in the degree of hepatic fibrosis and the condition of liver cell degeneration and necrosis, as revealed by HE staining and Masson staining, and the liver fibrosis scores were different among each treatment group (P < 0.05). Compared with group M, the liver fibrosis score of group A2 was improved most obviously (P < 0.01). Immunohistochemistry analysis showed that the expression of CK-18, ALB and AFP was different between each treatment group (P < 0.05). By labeling liver tissue stem cells with BrdU, the proliferation and division of stem cells were observed through the method of "regional coexistence". Immunofluorescence analysis revealed that the expression of CK-18, ALB and AFP were different among each treatment group (P < 0.01), with group A2 having the most prominent expression (P < 0.01). Liver function was improved differently in each treatment group (P < 0.05). Compared with group M, AST and ALT were decreased most significantly and ALB increased most obviously in group A2 (P < 0.01).

CONCLUSION: Wuweizi has a protective effect on injured liver cells. Wuweizi could delay the process of liver cirrhosis via mechanisms possibly related to promoting the proliferation of endogenous stem cells.