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Hanai T, Nishimura K, Unome S, Miwa T, Nakahata Y, Imai K, Suetsugu A, Takai K, Shimizu M. Alcohol-associated liver disease increases the risk of muscle loss and mortality in patients with cirrhosis. J Gastroenterol 2024:10.1007/s00535-024-02137-4. [PMID: 39068612 DOI: 10.1007/s00535-024-02137-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 07/18/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Rapid skeletal muscle loss adversely affects the clinical outcomes of liver cirrhosis. However, the relationships between the annual changes in skeletal muscle area (ΔSMA/year) and the etiology of cirrhosis, factors associated with muscle loss, and risk of mortality remains unclear. METHODS A total of 384 patients who underwent multiple computed tomography (CT) scans between March 2004 and June 2021 were enrolled in this study (median age, 67 years; 64% men; median model for end-stage liver disease score, 9). Body composition and ΔSMA/year were estimated using a 3D image analysis system and data from at least two distinct CT scans. Differences in ΔSMA/year among different etiologies of cirrhosis, factors associated with rapid muscle loss (defined as ΔSMA/year ≤ - 3.1%), and the association between ΔSMA/year and mortality were examined. RESULTS Patients with alcohol-associated liver disease (ALD) cirrhosis experienced more rapid muscle loss (ΔSMA/year, - 5.7%) than those with hepatitis B (ΔSMA/year, - 2.8%) and hepatitis C cirrhosis (ΔSMA/year, - 3.1%). ALD cirrhosis was independently associated with ΔSMA/year ≤ - 3.1% after adjusting for age, sex, and liver functional reserve. Over a median follow-up period of 3.8 years, ALD cirrhosis, ΔSMA/year ≤ - 3.1%, and low subcutaneous adipose tissue level were found to be significantly associated with reduced survival. ALD cirrhosis (hazard ratio [HR], 2.43; 95% confidence interval [CI] 1.12-5.28) and ΔSMA/year ≤ - 3.1% (HR, 3.68; 95% CI 2.46-5.52) were also predictive of mortality. CONCLUSIONS These results suggest that ALD cirrhosis increases the risk of rapid muscle loss and mortality in affected patients.
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Affiliation(s)
- Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan.
| | - Kayoko Nishimura
- Center for Nutrition Support and Infection Control, Gifu University Hospital, Gifu, Japan
| | - Shinji Unome
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Takao Miwa
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Yuki Nakahata
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Kenji Imai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Atsushi Suetsugu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Koji Takai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
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2
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Brown C, Hernandez R, Ford T, Aksan N, DiVincenzo C, Muir AJ. Inadequate Dietary Education and Poor Adherence to a High Protein, Low Sodium Diet in Cirrhosis: Mixed Methods Approach. Dig Dis Sci 2024:10.1007/s10620-024-08526-2. [PMID: 38940972 DOI: 10.1007/s10620-024-08526-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 06/10/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Malnutrition in cirrhosis is associated with poor outcomes, leading to guidelines for a high protein, low sodium diet; however, there is no guidance regarding the implementation of diet education in clinical practice. METHODS A mixed methods study enrolled 21 patients with cirrhosis and their caregivers. Semi-structured interviews on barriers and facilitators of dietary education and adherence were conducted. Demographic and clinical data were obtained, along with quantitative measures of dietary adherence, including 24-h food recall and spot urine sodium. Combined deductive and inductive coding was used to identify qualitative themes, along with a quantitative assessment of interviews. Quantitative data was reported using descriptive statistics with frequencies, mean and confidence intervals. RESULTS Participants were mostly male (16/21) with a mean age 57.8 years (SE 2.8) and MELD-Na 9 (SE 1.2). 4 themes emerged: 1. More than 50% of participants and caregivers endorsed no or inadequate diet education 2. They reported mostly negative experiences with dietary adherence with largest impact on social life 3. Facilitators of adherence included the presence of household support and fear of complications of cirrhosis 4. Overwhelmingly desired non-generic handouts and information. Dietary adherence was poor with only one participant meeting protein and sodium requirements based on food recall. Four participants who adhered to < 2000 mg sodium had inadequate daily caloric intake. CONCLUSIONS Dietary education is inadequate, and adherence to dietary recommendations is poor in patients with cirrhosis. Future studies should use these barriers and facilitators for intervention development.
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Affiliation(s)
- Cristal Brown
- Dell Medical School, University of Texas at Austin, 1601 Trinity St., Building B, Austin, TX, 78712, USA.
- Ascension Medical Group, 1601 Trinity St., Building B, Austin, TX, 78712, USA.
- University of Texas Health Austin, 1601 Trinity St Building A, Austin, TX, 78712, USA.
- University of Texas at Austin, Health Discovery Building 1601 Trinity St Z0900, Austin, TX, 78712, USA.
| | - Rabecca Hernandez
- Dell Medical School, University of Texas at Austin, 1601 Trinity St., Building B, Austin, TX, 78712, USA
| | - Ty Ford
- Dell Medical School, University of Texas at Austin, 1601 Trinity St., Building B, Austin, TX, 78712, USA
| | - Nazan Aksan
- Dell Medical School, University of Texas at Austin, 1601 Trinity St., Building B, Austin, TX, 78712, USA
| | - Clara DiVincenzo
- Dell Medical School, University of Texas at Austin, 1601 Trinity St., Building B, Austin, TX, 78712, USA
- Ascension Medical Group, 1601 Trinity St., Building B, Austin, TX, 78712, USA
- University of Texas Health Austin, 1601 Trinity St Building A, Austin, TX, 78712, USA
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, 300 W Morgan St., Durham, NC, 27701, USA
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Aerts M, Rosseel Z, De Waele E. The Evolution in Non-Alcoholic Fatty Liver Disease Patients' Profile and the Associated Sustainable Challenges: A Multidisciplinary Perspective. Nutrients 2024; 16:1584. [PMID: 38892517 PMCID: PMC11174485 DOI: 10.3390/nu16111584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/06/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
The prevalence and incidence of NAFLD is rising due to the obesity pandemic, caused by the widespread availability of ultra-processed foods and the decrease of physical activity. Factors such as socioeconomic status (SES), ethnicity and geographical location are associated with NAFLD, with lower SES correlating with higher incidence, particularly in regions like America or Europe. Beside the quality of food, the quantity also plays a crucial role. The World Health Organization (WHO) recommends a Mediterranean diet with a balanced energy intake. Since no hard medical treatment is available for NAFLD, lifestyle adjustments are key. Patient empowerment by providing relevant information and co-ownership of the therapy will increase the implementation rate and enhance the quality of medical follow-up and medication adherence, as studies report a good adherence to medication among patients who are well-aware of the severity of their disease. Regarding sustainability, patients with NAFLD have a high load of ambulatory follow-up, which, since the COVID-19 pandemic, can be partially provided by teleconsulting. Both patients' lifestyle modifications and healthcare practitioners' therapeutical strategy can decrease the carbon footprint.
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Affiliation(s)
- Maridi Aerts
- Department of Gastroenterology and Hepatology, Universitair Ziekenhuis Brussel (UZB), 1090 Brussels, Belgium;
| | - Zenzi Rosseel
- Department of Pharmacy, Universitair Ziekenhuis Brussel (UZB), 1090 Brussels, Belgium
- Department of Clinical Nutrition, Universitair Ziekenhuis Brussel (UZB), 1090 Brussels, Belgium;
| | - Elisabeth De Waele
- Department of Clinical Nutrition, Universitair Ziekenhuis Brussel (UZB), 1090 Brussels, Belgium;
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), 1090 Brussels, Belgium
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4
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Hanai T, Nishimura K, Unome S, Miwa T, Nakahata Y, Imai K, Suetsugu A, Takai K, Shimizu M. Nutritional counseling improves mortality and prevents hepatic encephalopathy in patients with alcohol-associated liver disease. Hepatol Res 2024. [PMID: 38683882 DOI: 10.1111/hepr.14053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/02/2024] [Accepted: 04/12/2024] [Indexed: 05/02/2024]
Abstract
AIM Nutritional counseling improves malnutrition, which determines the prognosis of patients with chronic liver disease. In this study, we investigated the effects of nutritional counseling on mortality and the risk of overt hepatic encephalopathy (HE) in patients with alcohol-associated liver disease. METHODS In this retrospective cohort study, we included 211 patients with alcohol-associated liver disease who visited Gifu University Hospital between August 2008 and June 2023. Patients were classified into two groups according to the frequency of nutritional counseling by a registered dietitian. The primary outcomes were all-cause mortality and overt HE. Propensity score matching analysis was performed to adjust for potential confounders. RESULTS Among the patients (median age 67 years; 88% men; and median Model for End-Stage Liver Disease score, 9), 86 (39%) were in the high-frequency (≥2) nutritional counseling group. The high-frequency group had a significantly higher survival rate (46% vs. 25%) and a lower incidence of overt HE (16% vs. 27%) at 5 years than the low-frequency group. Nutritional counseling was associated with a reduced risk of mortality (hazard ratio [HR] 0.48; 95% confidence interval [CI] 0.36-0.63) and overt HE (HR 0.64; 95% CI 0.42-0.99), independent of hepatocellular carcinoma and liver function reserve. After propensity score matching, nutritional counseling was still associated with a reduced risk of mortality (HR 0.34; 95% CI 0.19-0.59) and overt HE (HR 0.31; 95% CI 0.11-0.87). CONCLUSIONS Nutritional counseling effectively improves mortality and prevents overt HE in patients with alcohol-associated liver disease, thereby proving essential for the management of these patients.
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Affiliation(s)
- Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kayoko Nishimura
- Center for Nutrition Support and Infection Control, Gifu University Hospital, Gifu, Japan
| | - Shinji Unome
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takao Miwa
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yuki Nakahata
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kenji Imai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Atsushi Suetsugu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Koji Takai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
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Bruns N, Meyer F, Rischmüller K, Frost F, Tran QT, Ittermann T, Bahls M, Valentini L, Lamprecht G, Lerch MM, Aghdassi AA, Wiese ML. Nutritional status in patients with chronic pancreatitis and liver cirrhosis is related to disease conditions and not dietary habits. Sci Rep 2024; 14:4700. [PMID: 38409360 PMCID: PMC10897307 DOI: 10.1038/s41598-024-54998-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/19/2024] [Indexed: 02/28/2024] Open
Abstract
Malnutrition is a common complication of chronic pancreatitis (CP) and liver cirrhosis (LC). Inadequate food intake is considered a relevant driver of malnutrition in both entities. However, the contribution of habitual diet to impaired nutritional status is unclear. In a prospective, multicenter cross-sectional study, we recruited patients with confirmed CP or LC and healthy volunteers as a control group. Malnutrition was diagnosed according to the Global Leadership Initiative on Malnutrition criteria. We comprehensively investigated habitual dietary intake on nutrient, food group, and dietary pattern level applying two validated food frequency questionnaires. We included 144 patients (CP: n = 66; LC: n = 78) and 94 control subjects. Malnutrition was prevalent in 64% and 62% of patients with CP or LC, respectively. In both CP and LC, despite slightly altered food group consumption in malnourished and non-malnourished patients there were no differences in energy or nutrient intake as well as dietary quality. Compared to controls patients showed distinct dietary food group habits. Patients consumed less alcohol but also lower quantities of fruits and vegetables as well as whole grain products (p < 0.001, respectively). Nevertheless, overall dietary quality was comparable between patients and healthy controls. Nutritional status in CP and LC patients is rather related to disease than habitual dietary intake supporting the relevance of other etiologic factors for malnutrition such as malassimilation or chronic inflammation. Despite distinct disease-related differences, overall dietary quality in patients with CP or LC was comparable to healthy subjects, which suggests susceptibility to dietary counselling and the benefits of nutrition therapy in these entities.
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Affiliation(s)
- Niklas Bruns
- Department of Medicine A, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Fatuma Meyer
- Institute of Evidence-Based Dietetics (NIED), University of Applied Sciences Neubrandenburg, Neubrandenburg, Germany
| | - Karen Rischmüller
- Division of Gastroenterology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - Fabian Frost
- Department of Medicine A, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Quang Trung Tran
- Department of Medicine A, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Till Ittermann
- Institute for Community Medicine, University of Greifswald, Greifswald, Germany
| | - Martin Bahls
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
| | - Luzia Valentini
- Institute of Evidence-Based Dietetics (NIED), University of Applied Sciences Neubrandenburg, Neubrandenburg, Germany
| | - Georg Lamprecht
- Division of Gastroenterology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - Markus M Lerch
- Department of Medicine A, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
- LMU University Hospital, Ludwig Maximilian Universität München, Munich, Germany
| | - Ali A Aghdassi
- Department of Medicine A, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany.
| | - Mats L Wiese
- Department of Medicine A, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
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6
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Topan MM, Sporea I, Dănilă M, Popescu A, Ghiuchici AM, Lupușoru R, Șirli R. Association between Dietary Habits and Sarcopenia in Patients with Liver Cirrhosis. J Clin Med 2023; 12:4693. [PMID: 37510811 PMCID: PMC10380646 DOI: 10.3390/jcm12144693] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
Sarcopenia and sarcopenic obesity are frequent complications of cirrhosis, and the dietary patterns of patients with these diseases significantly impact the development of both conditions. This study aims to evaluate the adequacy of the dietary intake of patients with liver cirrhosis. A total of 201 patients with liver cirrhosis were included in this analysis. We evaluated the nutritional status of the patients as stated by EWGSOP2 criteria. Subjects were divided into three groups: non-sarcopenic, sarcopenic, and with sarcopenic obesity. We conducted a dietary assessment three times over nonconsecutive 24 h periods within a month. According to EWGSOP2 criteria, combining low handgrip strength with low skeletal muscle index, the prevalence of sarcopenia was 57.2%. Sarcopenic obesity was found in 25.3% of patients. In the sarcopenic group of patients, the energy intake was lower than the current recommendations. Regarding protein intake, the consumption was relatively low in both sarcopenia and sarcopenic obesity samples of patients (0.85 g/kg body weight and 0.77 g/kg BW, p < 0.0001). Patients had a median of 2-3 eating episodes daily, and they often missed late-evening snacks. In conclusion, diet quality in cirrhotic patients was relatively poor, and energy and protein intakes were lower than suggested.
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Affiliation(s)
- Mirabela-Madalina Topan
- Department of Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Ioan Sporea
- Department of Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Mirela Dănilă
- Department of Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Alina Popescu
- Department of Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Ana-Maria Ghiuchici
- Department of Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Raluca Lupușoru
- Department of Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Center for Modeling Biological Systems and Data Analysis, Department of Functional Science, "Victor Babeș" University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Roxana Șirli
- Department of Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, 300041 Timișoara, Romania
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7
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Parisse S, Carnevale S, Di Bartolomeo F, Poli E, Miceli F, Ferri F, Mischitelli M, Rocco B, Lai Q, Lucatelli P, Corona M, Mennini G, De Santis A, Rossi M, Muscaritoli M, Cantafora A, Ginanni Corradini S. A Low Daily Intake of Simple Sugars in the Diet Is Associated with Improved Liver Function in Cirrhotic Liver Transplant Candidates. Nutrients 2023; 15:nu15071575. [PMID: 37049416 PMCID: PMC10097197 DOI: 10.3390/nu15071575] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/19/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
(1) Background: We investigated, for the first time, whether dietary simple sugar intake affects MELD score changes over time in a cohort of cirrhotic liver transplant candidates. (2) Methods: the MELD score, dietary habits using a 3-day food diary, and visceral adipose tissue index (VATI) measured with CT scan were assessed in 80 consecutive outpatient cirrhotic patients at baseline, after counseling to follow current nutritional guidelines. The MELD score was reassessed after six months and the DELTA-MELD was calculated as the MELD at the second assessment minus the MELD at baseline. (3) Results: Compared with the baseline, the MELD score of cirrhotic patients at the end of the study was decreased, stable, or increased in 36%, 8% and 56% of patients, respectively. In separate multiple linear regression models, DELTA-MELD was positively and independently correlated with the daily intake of simple sugars expressed in g/kg body weight (p = 0.01) or as a percentage of total caloric intake (p = 0.0004) and with the number of daily portions of fruit, added sugar, jam, and honey (p = 0.003). These associations were present almost exclusively in patients with VATI above the median value. (4) Conclusions: In cirrhotic patients with high amounts of visceral adipose tissue the consumption of simple sugars and fructose should be limited to improve their clinical outcome.
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Affiliation(s)
- Simona Parisse
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | | | - Francesca Di Bartolomeo
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Edoardo Poli
- Centre Hépato-Biliaire, Hôpital Paul Brousse, AP-HP, 94800 Villejuif, France
| | - Francesca Miceli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Flaminia Ferri
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Monica Mischitelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Bianca Rocco
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Pierleone Lucatelli
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Mario Corona
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Gianluca Mennini
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Adriano De Santis
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Massimo Rossi
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Maurizio Muscaritoli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Alfredo Cantafora
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
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