Patient-Generated Subjective Global Assessment and Computed Tomography in the assessment of malnutrition and sarcopenia in patients with cirrhosis: Is there any association?

Screening and assessment of malnutrition in patients with liver cirrhosis

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

Effects of protein-enriched nutritional support on skeletal muscle mass and rehabilitative outcomes in brain tumor patients: a randomized controlled trial

Patients with brain tumors require extensive and prolonged rehabilitation efforts as they suffer from lesion-induced motor weakness as well as treatment-related side effects, often leading to a significant decline in function. Protein supplements have shown positive effects on promoting muscle strength and physical performance in various tumor etiologies. However, reports on their effects specifically in brain tumor patients remain scarce. This study aims to investigate the feasibility and efficacy of protein supplements in enhancing rehabilitative outcomes via muscle strengthening and functional gain in brain tumor patients with neurological demise. Sixty brain tumor patients were randomly assigned to either a protein supplement or a control group, receiving either protein supplements or a placebo for 6 weeks, in conjunction with conventional rehabilitation therapy. Assessments before and after the intervention included laboratory tests, anthropometric measures using bioimpedance analysis, and functional assessments, which included the MMSE, the modified Barthel Index, the Beck Depression Inventory, the Brief Fatigue Inventory, the Timed Up and Go test, the 6-min walk test, the isokinetic quadriceps muscle strength test, and the handgrip power. After the intervention, the levels of serum hemoglobin, protein, albumin, and C-reactive protein were improved in both groups, however, the change was significant only in the protein group. The muscle strength was enhanced in both groups, however, the significant increase in pinch grasp power was only noted in the protein group (P < 0.05). The distance on 6MWT was also significantly extended at follow-up in the protein group (P < 0.01). In the subgroup analysis according to nutritional status, the moderate malnutrition group showed greater augmentation of muscle mass than those with adequate nutrition (P < 0.05). Interestingly, the amelioration of malnutrition was observed only the in protein group. This study using protein supplements to promote the rehabilitative potential of brain tumor patients revealed a significant effect on improving hemodynamic nutritional indices, muscle power reimbursement, and functional improvement, especially in malnourished patients. The safety and feasibility of protein supplements in brain tumor patients were affirmative in this study. Further studies with more patients may help confirm the secondary functional gain resulting from increased muscle power.Trial registration: This study was retrospectively registered in the Clinical Research Information Service, CRIS no. KCT0009113 on Jan 12, 2024.

Malnutrition and its association with the mortality in liver cirrhosis; a prospective nutritional assessment in two referral centers in Iran

INTRODUCTION

Liver cirrhosis is a chronic condition caused by different conditions including viral infection, alcoholism, and autoimmune disorders. Malnutrition is one of the complications of liver cirrhosis that is associated with poor outcomes. This study aimed to determine the association of malnutrition with mortality in liver cirrhosis patients.

METHODS

This prospective cross-sectional study was conducted on liver cirrhosis patients who were referred to two referral centers for liver disease in Tehran, Iran. Patients' information including demographics (age, gender, etiology of cirrhosis, alcohol and smoking history) in addition to triceps skinfold (TSF), mid-arm circumference (MAC), Child-Pugh score and Model for End-Stage Liver Disease (MELD) score were recorded in all patients. Patients were classified into A, B, and C categories based on the Subjective Global Assessment (SGA) questionnaire.

RESULTS

Among 121 participants (68.6%) were males and the mean age was 54.78. Viral infections were the most common etiology and 65 patients (56.2%) were in the classification A of Child-Pugh Score. TSF (P = 0.001) and MAC (P = 0.003) were significantly lower in SGA class C. The survival rate in SGA class C was significantly lower than other groups (P < 0.001; log-rank test). The risk of mortality in patients with SGA class A and B was 85% (HR value: 0.15; 95% CI: 0.02-0.87; P = 0.03) and 76% (HR value: 0.24; 95% CI: 0.06-0.83; P = 0.02) lower than those with SGA class C.

CONCLUSION

Anthropometric and SGA measure are two easy and accessible methods for assessing malnutrition and mortality in liver cirrhosis patients.

Power of mortality prediction in patients awaiting liver transplantation according to the Global Leadership Initiative on Malnutrition criteria and Subjective Global Assessment and Royal Free Hospital Global Assessment scores

OBJECTIVES

This study aimed to analyze the performance of the Global Leadership Initiative on Malnutrition (GLIM) criteria and Subjective Global Assessment (SGA) and Royal Free Hospital Global Assessment (RFH-GA) scores in predicting 12-mo mortality in patients awaiting liver transplantation.

METHODS

This is a longitudinal observational study, carried out between March 2019 and November 2021. Clinical data were collected and nutritional assessment was performed through anthropometry and application of validated instruments, such as the SGA, GLIM criteria, and RFH-GA. A Cox regression model was carried out, in which the dependent variable was mortality in 1 y, and the independent variables were the classifications of nutritional status by the different methods.

RESULTS

The sample consisted of 126 patients, most of them male (56.35%). Malnutrition was diagnosed in 85.71% of the patients according to the RFH-GA, 62.70% according to the SGA, and 56.31% according to the GLIM criteria. Malnutrition assessed by GLIM was related to a 3.79-fold increase in the chance of mortality over time in patients awaiting liver transplantation. Moreover, the GLIM criteria had good discriminatory power in identifying mortality in patients awaiting liver transplantation, compared with the initial and final SGA and RFH-GA scores and the Model for End-stage Liver Disease-Sodium (MELD-Na) index.

CONCLUSIONS

The GLIM criteria were a good predictor of increased risk of mortality in malnourished patients with chronic liver disease awaiting liver transplantation, compared with the SGA and RFH-GA scores and the MELD-Na index.

Function Over Mass: A Meta-Analysis on the Importance of Skeletal Muscle Quality in COVID-19 Patients

COVID-19 caused by SARS-CoV-2 infection is a highly contagious disease affecting both the higher and lower portions of the respiratory tract. This disease reached over 265 million people and has been responsible for over 5.25 million deaths worldwide. Skeletal muscle quality and total mass seem to be predictive of COVID-19 outcome. This systematic review aimed at providing a critical analysis of the studies published so far reporting on skeletal muscle mass in patients with COVID-19, with the intent of examining the eventual association between muscle status and disease severity. A meta-analysis was performed to evaluate whether skeletal muscle quantity, quality and function were related to disease severity. Systematic reviews and meta-analyses were conducted according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions and reported according to the guidelines of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guide. From a total of 1,056 references found, 480 were selected after removing duplicates. Finally, only 7 met the specified inclusion criteria. The results of this meta-analysis showed that skeletal muscle quality, rather than quantity, was associated with COVID-19 severity, as confirmed by lower skeletal muscle density and lower handgrip strength in patients with severe disease. Muscle function assessment can thus be a valuable tool with prognostic value in COVID-19.

Progressive Skeletal Muscle Loss After Surgery and Adjuvant Radiotherapy Impact Survival Outcomes in Patients With Early Stage Cervical Cancer

The effect of skeletal muscle loss associated with surgery and adjuvant radiotherapy on survival outcomes in patients with early-stage cervical cancer remains unclear. We analyzed the data of 133 patients with early-stage cervical cancer who underwent surgery and adjuvant radiotherapy between 2013 and 2018 at two tertiary centers. Skeletal muscle changes were measured using computed tomography scans at baseline, at simulation for radiotherapy, and at 3 months post-treatment. A decrease of ≥5% in the skeletal muscle was defined as “muscle loss.” The Patient-Reported Outcome version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) was used to assess gastrointestinal toxicity. The Patient-Generated Subjective Global Assessment (PG-SGA) was used for nutritional assessment. Predictors of overall survival were identified using the Cox regression models. The median follow-up period was 3.7 years. After treatment, 32 patients (24.1%) experienced muscle loss. The rate of muscle loss was higher in patients with PRO-CTCAE score ≥3 or PG-SGA score ≥4 at the end of radiotherapy than in patients with PRO-CTCAE score ≤2 or PG-SGA score 0–3 (75.0 vs. 10.5%, p < 0.001; 71.4 vs. 2.2%, p < 0.001). The 3-year overall survival was significantly lower in patients with muscle loss than in those with muscle preserved (65.6 vs. 93.9%, p < 0.001). Multivariate analysis showed that muscle loss was independently associated with poor overall survival (hazard ratio, 4.55; 95% confidence interval: 1.63–12.72; p < 0.001). Muscle loss after surgery and adjuvant radiotherapy was associated with poor overall survival in patients with early-stage cervical cancer. Muscle loss is associated with patient-reported gastrointestinal toxicity and deterioration in nutritional status.

Visceral Adiposity Associates With Malnutrition Risk Determined by Royal Free Hospital-Nutritional Prioritizing Tool in Cirrhosis

Mounting evidence has suggested the clinical significance of body composition abnormalities in the context of cirrhosis. Herein, we aimed to investigate the association between visceral adiposity and malnutrition risk in 176 hospitalized patients with cirrhosis. The adiposity parameters were obtained by computed tomography (CT) as follows: total adipose tissue index (TATI), visceral adipose tissue index (VATI), subcutaneous adipose tissue index (SATI), and visceral to subcutaneous adipose tissue area ratio (VSR). Malnutrition risk was screened using Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT). Visceral adiposity was determined given a higher VSR based on our previously established cutoffs. Multivariate analysis implicated that male gender (OR = 2.884, 95% CI: 1.360–6.115, p = 0.006), BMI (OR = 0.879, 95% CI: 0.812–0.951, P = 0.001), albumin (OR = 0.934, 95% CI: 0.882–0.989, P = 0.019), and visceral adiposity (OR = 3.413, 95% CI: 1.344–8.670, P = 0.010) were independent risk factors of malnutrition risk. No significant difference was observed regarding TATI, SATI, and VATI among patients with low or moderate and high risk of malnutrition. In contrast, the proportion of male patients embracing visceral adiposity was higher in high malnutrition risk group compared with that in low or moderate group (47.27 vs. 17.86%, p = 0.009). Moreover, this disparity was of borderline statistical significance in women (19.05 vs. 5.88%, p = 0.061). Assessing adipose tissue distribution might potentiate the estimation of malnutrition risk in cirrhotics. It is pivotal to recognize visceral adiposity and develop targeted therapeutic strategies.

Association of Patient-Reported Outcomes and Nutrition with Body Composition in Women with Gynecologic Cancer Undergoing Post-Operative Pelvic Radiotherapy: An Observational Study

Pelvic radiotherapy is associated with gastrointestinal toxicities and deterioration of nutritional status. This study aimed to investigate the association of patient-reported outcomes (PROs) and nutritional status with body composition changes in women who underwent hysterectomy and post-operative radiotherapy for gynecologic cancer. We analyzed data of 210 patients treated with post-operative pelvic radiotherapy for gynecologic cancer between 2013 and 2018. The PRO version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) was used for gastrointestinal toxicity assessment. The Patient-Generated Subjective Global Assessment (PG-SGA) was used for nutritional assessment. Skeletal muscle index was measured from computed tomography scans at the L3 vertebral level. A reduction in skeletal muscle index ≥ 5% was classified as muscle loss. Odds ratios were calculated through logistic regression models. The PG-SGA score increased from the beginning to the end of radiotherapy (1.4 vs. 3.7, p < 0.001). Patients with PRO-CTCAE scores ≥ 3 had significantly higher PG-SGA scores at the end of radiotherapy than those with PRO-CTCAE scores ≤ 2 (8.1 vs. 2.3, p < 0.001). On multivariable analysis, PRO-CTCAE scores ≥ 3 and PG-SGA scores ≥ 4 at the end of radiotherapy were independently associated with increased risk of muscle loss (odds ratio: 8.81, p < 0.001; odds ratio: 72.96, p < 0.001, respectively). PROs and PG-SGA may be considered as markers of muscle loss after post-operative pelvic radiotherapy for gynecologic cancer.

Myopenic obesity determined by visceral fat area strongly predicts long-term mortality in cirrhosis

BACKGROUND

The impact of changes in body composition has proved to correlate with outcomes in cirrhosis, however, numerous issues remain elusive. The present study aimed to investigate the prognostic value of myopenic obesity (MO) on long-term mortality in cirrhosis.

METHODS

We retrospectively analyzed 200 patients with cirrhosis. Body composition parameters including skeletal muscle index (SMI) and visceral fat area (VFA) were estimated by computed tomography images at the third lumbar vertebra level. We defined MO as a low SMI (male: SMI < 46.96 cm²/m² and female: SMI < 32.46 cm²/m²) with BMI ≥ 25 kg/m² or VFA ≥ 100 cm² according to our previous publication. Patients were categorized into one of four body composition groups in terms of the presence or absence of myopenia and obesity.

RESULTS

On the basis of VFA or BMI, the four group comparison demonstrated the prognosis was poor in MO, followed by myopenic/nonobesity (MN), nonmyopenic/obesity and nonmyopenic/nonobesity, in that order (log-rank test). Multivariate Cox analysis identified that MO (HR 2.498; 95% CI, 1.214-5.140; P = 0.013), MN (HR 2.763; 95% CI, 1.244-6.134; P = 0.013), age (HR 3.035; 95% CI, 1.904-4.839; P < 0.001), neutrophil-to-lymphocyte ratio (HR 1.142; 95% CI, 1.082-1.207; P < 0.001) and MELD (HR 1.140; 95% CI, 1.066-1.219; P = 0.001) were independently associated with 2-year mortality according to VFA classification.

CONCLUSIONS

MO was an independent predictor of higher long-term mortality in cirrhosis. Prevention strategies by reducing visceral fat obesity rather than BMI should be the optimal target for MO management.

The Impact of Protein Supplementation Targeted at Improving Muscle Mass on Strength in Cancer Patients: A Scoping Review

Deterioration of muscle strength during cancer results in functional limitation, poor quality of life and reduced survival. The indirect effects on muscle strength of nutritional interventions based on protein and amino acid derivatives targeted at improving muscle mass are poorly documented. A scoping review was performed to examine the available evidence on the effects of proteins, amino acids and their derivatives on muscle strength in adult cancer patients. Pubmed and Scopus databases were searched to identify research articles published in the last 10 years. Fourteen studies met the inclusion criteria, showing that changes in muscle strength following protein or amino acid supplementation are generally concordant with those in muscle mass in cancer patients. Administration of both energy and proteins in the presence of reduced oral intakes results in more robust effects on both muscle strength and mass. It is not clear whether this is due to the correction of the energy deficit or to an interaction between proteins and other macronutrients. The optimal mixture, type, and dose of amino acid/protein supplementation alone or in combination with other anabolic strategies should be determined to provide the best nutritional approach in cancer.