Association of CT-based diagnosis of sarcopenia with prognosis and treatment response in patients at risk of malnutrition - A secondary analysis of the Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) trial

Sex differences in the association between chest computed tomography-defined sarcopenia and cardiovascular risk factors among inpatients

Background

While sarcopenia has been found to be associated with increased risks of cardiovascular diseases (CVDs), evidence exploring sex-related differences remains insufficient. This study aimed to investigate the differences in how often sarcopenia occurs in each sex, as determined by skeletal muscle area (SMA) in chest CT images, and its association with CVD common risk factors.

Methods

This cross-sectional study involved 1,340 inpatients from the Department of Geriatrics of Renji Hospital, affiliated to Shanghai Jiaotong University School of Medicine. Data on age, sex, body mass index (BMI), smoking status, disease history, and clinical parameters were collected. Sarcopenia was defined using chest CT images with a cut-off value of T12-SMA/height2 <25.75 cm2/m2 in male patients and <20.16 cm2/m2 in female patients. Cardiovascular risk was assessed using the Framingham risk score (FRS). The association between T12-SMA/height2-defined sarcopenia and CVD risk factors by sex was evaluated using a multivariate logistic regression analysis.

Results

The overall prevalence of T12-SMA/height2-defined sarcopenia (<25.75 cm2/m2 for male patients, <20.16 cm2/m2 for female patients) was 54.03%, with 48.09% in male patients and 63.19% in female patients. The proportion of male patients with high CVD risk was greater than that of female patients. The multivariate analysis revealed that T12-SMA/height2-defined sarcopenia was independently associated with age (in male patients only), systolic blood pressure (SBP), cholesterol, and high-density lipoprotein cholesterol (HDL-C) among the six FRS cardiovascular risk indices.

Conclusion

Our results suggest that T12-SMA/height2-defined sarcopenia was more prevalent in male patients than in female patients. Sarcopenia was associated with higher levels of SBP and HDL-C and lower levels of cholesterol. Increasing age had a more significant effect on CVD risk in male patients.

Muscle matters: Prognostic implications of malnutrition and muscle health parameters in patients with cancer. A secondary analysis of a randomised trial

BACKGROUND

Low muscle mass and malnutrition are independently associated with an increased risk of adverse outcomes in patients with cancer. However, it is not yet clear which parameter is most indicative of these risks. This study investigates the prognostic significance of different parameters reflecting malnutrition and muscle health in a well-characterised oncology population at nutritional risk.

METHODS

This preplanned secondary analysis included patients with cancer from a Swiss-wide, randomised-controlled nutritional trial. We investigated associations among malnutrition markers (i.e., malnutrition diagnosis based on modified Global Leadership Initiative on Malnutrition (GLIM) criteria, albumin concentration) and muscle health markers (i.e., hand grip strength, computed tomography (CT)-based muscle mass and radiodensity) with 180-day all-cause mortality (primary outcome).

RESULTS

We included 269 patients with a main admission diagnosis of cancer and available CT scans. In a mutually adjusted model, four parameters contributed to risk assessment including modified malnutrition diagnosis (GLIM) (HR 1.78 (95%CI 1.17 to 2.69), p = 0.007, AUC 0.58), low albumin concentration (HR 1.58 (95%CI 1.08 to 2.31), p = 0.019, AUC 0.62), low handgrip strength (HR 2.05 (95%CI 1.43 to 2.93), p = 0.001, AUC 0.62) and low muscle radiodensity (HR 1.39 (95%CI 0.90 to 2.16), p = 0.139, AUC 0.63). Combining these parameters resulted in a model with high prognostic power regarding 180-day mortality (overall AUC 0.71).

CONCLUSIONS

In this study of inpatients with cancer at nutritional risk, several malnutrition and muscle health parameters emerged as independent prognostic indicators for mortality. The use of these parameters may improve risk stratification and guide nutritional interventions in this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT02517476.

The Association of the Essential Amino Acids Lysine, Methionine, and Threonine with Clinical Outcomes in Patients at Nutritional Risk: Secondary Analysis of a Randomized Clinical Trial

Lysine, methionine, and threonine are essential amino acids with vital functions for muscle and connective tissue health, metabolic balance, and the immune system. During illness, the demand for these amino acids typically increases, which puts patients at risk for deficiencies with harmful clinical consequences. In a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), which compared individualized nutritional support to usual care nutrition in patients at nutritional risk, we investigated the prognostic impact of the lysine, methionine, and threonine metabolism. We had complete clinical and amino acid data in 237 patients, 58 of whom reached the primary endpoint of death at 30 days. In a model adjusted for comorbidities, sex, nutritional risk, and trial intervention, low plasma methionine levels were associated with 30-day mortality (adjusted HR 1.98 [95% CI 1.16 to 3.36], p = 0.01) and with a decline in functional status (adjusted OR 2.06 [95% CI 1.06 to 4.01], p = 0.03). The results for lysine and threonine did not show statistically significant differences regarding clinical outcomes. These findings suggest that low levels of methionine may be critical during hospitalization among patients at nutritional risk. Further studies should investigate the effect of supplementation of methionine in this patient group to improve outcomes.

Performance of anthropometry-based and bio-electrical impedance-based muscle-mass indicators in the Global Leadership Initiative on Malnutrition criteria for predicting prognosis in patients with cancer

BACKGROUND

Reduced muscle mass is a criterion for diagnosing malnutrition using the Global Leadership Initiative on Malnutrition (GLIM) criteria; however, the choice of muscle-mass indicators within the GLIM criteria remains contentious. This study aimed to establish muscle-measurement-based GLIM criteria using data from bio-electrical impedance analysis (BIA) and anthropometric evaluations and evaluate their ability to predict overall survival (OS), short-term outcomes, and healthcare burden in patients with cancer.

METHODS

This was a multicenter, prospective study that commenced in 2013 and enrolled participants from various clinical centers across China. We constructed GLIM criteria based on various muscle measurements, including fat-free mass index (FFMI), skeletal muscle index (SMI), calf circumference (CC), midarm circumference (MAC), midarm muscle circumference (MAMC), and midarm muscle area (MAMA). Survival was estimated using the Kaplan-Meier method and survival curves were compared using the log-rank test. Cox proportional hazards regression was used to assess the independent association between the GLIM criteria and OS. The discriminatory performance of different muscle-measurement-based GLIM criteria for mortality was evaluated using Harrell's concordance index (C-index). Logistic regression was used to evaluate the association of the GLIM criteria with short-term outcomes and healthcare burden.

RESULTS

A total of 4769 patients were included in the analysis, of whom 1659 (34.8%) died during the study period. The Kaplan-Meier curves demonstrated that all muscle-measurement-based GLIM criteria significantly predicted survival in patients with cancer (all p < 0.001). The survival rate of malnourished patients was approximately 10% lower than that of non-malnourished patients. Cox proportional hazards regression showed that all the muscle-measurement-based GLIM could independently predict the OS of patients (all p < 0.001). The prognostic discrimination was as follows: MAMC (Chi-square: 79.61) > MAMA (Chi-square: 79.10) > MAC (Chi-square: 64.09) > FFMI (Chi-square: 62.33) > CC (Chi-square: 58.62) > ASMI (Chi-square: 57.29). In comparison to the FFMI-based GLIM criteria, the ASMI-based criteria (-0.002, 95% CI: -0.006 to 0.002, p = 0.334) and CC-based criteria (-0.003, 95% CI: -0.007 to 0.002, p = 0.227) did not exhibit a significant advantage. However, the MAC-based criteria (0.001, 95% CI: -0.003 to 0.004, p = 0.776), MAMA-based criteria (0.004, 95% CI: 0.000-0.007, p = 0.035), and MAMC-based criteria (0.005, 95% CI: 0.000-0.007, p = 0.030) outperformed the FFMI-based GLIM criteria. Logistic regression showed that muscle measurement-based GLIM criteria predicted short-term outcomes and length of hospital stay in patients with cancer.

CONCLUSION

All muscle measurement-based GLIM criteria can effectively predict OS, short-term outcomes, and healthcare burden in patients with cancer. Anthropometric measurement-based GLIM criteria have potential for clinical application as an alternative to BIA-based measurement.

A Comparison of High and Usual Protein Dosing in Critically Ill Patients With Obesity: A Post Hoc Analysis of an International, Pragmatic, Single-Blinded, Randomized Clinical Trial

OBJECTIVES

Across guidelines, protein dosing for critically ill patients with obesity varies considerably. The objective of this analysis was to evaluate whether this population would benefit from higher doses of protein.

DESIGN

A post hoc subgroup analysis of the effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein): an international, multicenter, pragmatic, registry-based randomized trial.

SETTING

Eighty-five adult ICUs across 16 countries.

PATIENTS

Patients with obesity defined as a body mass index (BMI) greater than or equal to 30 kg/m 2 ( n = 425).

INTERVENTIONS

In the primary study, patients were randomized into a high-dose (≥ 2.2 g/kg/d) or usual-dose protein group (≤ 1.2 g/kg/d).

MEASUREMENTS AND MAIN RESULTS

Protein intake was monitored for up to 28 days, and outcomes (time to discharge alive [TTDA], 60-d mortality, days of mechanical ventilation [MV], hospital, and ICU length of stay [LOS]) were recorded until 60 days post-randomization. Of the 1301 patients in the primary study, 425 had a BMI greater than or equal to 30 kg/m 2 . After adjusting for sites and covariates, we observed a nonsignificant slower rate of TTDA with higher protein that ruled out a clinically important benefit (hazard ratio, 0.78; 95% CI, 0.58-1.05; p = 0.10). We found no evidence of difference in TTDA between protein groups when subgroups with different classes of obesity or patients with and without various nutritional and frailty risk variables were examined, even after the removal of patients with baseline acute kidney injury. Overall, 60-day mortality rates were 31.5% and 28.2% in the high protein and usual protein groups, respectively (risk difference, 3.3%; 95% CI, -5.4 to 12.1; p = 0.46). Duration of MV and LOS in hospital and ICU were not significantly different between groups.

CONCLUSIONS

In critically ill patients with obesity, higher protein doses did not improve clinical outcomes, including those with higher nutritional and frailty risk.

Prevalence and clinical outcomes of sarcopenia in patients with esophageal, gastric or colorectal cancers receiving preoperative neoadjuvant therapy: A meta-analysis

Objective

To investigate the prevalence of sarcopenia and its impact on clinical outcomes in patients with esophageal, gastric, or colorectal cancer (EC, GC, and CRC) receiving neoadjuvant therapy through Meta-analysis.

Methods

We searched the PubMed, Embase databases, and Cochrane Library for the prevalence of sarcopenia and its impact on clinical outcomes in EC, GC, or CRC patients treated with neoadjuvant therapy (NAT) from inception to November 2022. The primary endpoints were the prevalence of sarcopenia and overall survival in patients with EC, GC, or CRC treated with NAT. Secondary outcomes included recurrence-free survival, total postoperative complications, grade 3-4 chemotherapy toxicity, and 30-day mortality after surgery.

Results

Thirty-one retrospective studies with 3651 subjects were included. In a fixed-effects model, the prevalence of muscle loss was higher in patients with EC, GC, or CRC at 50% (95% CI ​= ​42% to 58%). The results of the multivariate analysis showed that preoperative patients with sarcopenia had a 1.91 times shorter overall survival (95% CI ​= ​1.61-2.27) and a 1.77 times shorter recurrence-free survival time (95% CI ​= ​1.33-2.35) than patients without sarcopenia, and that patients with sarcopenia had a higher risk of total postoperative complications than patients without sarcopenia OR ​= ​1.27 (95% CI ​= ​1.03-1.57). However, the two groups had no statistical difference in grade 3-4 chemotherapy toxicity (P ​= ​0.84) or 30-d postoperative mortality (P ​= ​0.88).

Conclusions

The prevalence of sarcopenia in patients with EC, GC, or CRC during NAT is high, and it is associated with poorer clinical outcomes. Clinicians should closely monitor the changes in patients' body composition and guide patients to carry out a reasonable diet and appropriate exercise to improve their poor prognosis and quality of life.

Systematic review registration

CRD42023387817.

Sarcopenia predicts postoperative complications and survival in colorectal cancer patients with GLIM-defined malnutrition: Analysis from a prospective cohort study

OBJECTIVE

To investigate whether sarcopenia could predict postoperative outcomes in patients with colorectal cancer with Global Leadership Initiative on Malnutrition (GLIM)-defined malnutrition.

METHODS

Clinical data of patients who underwent radical resection for colorectal cancer were prospectively collected. Sarcopenia was diagnosed by the combination of low handgrip strength and low muscle quantity or quality as measured by abdominal computed tomography (CT) images. Logistic regression analysis and Cox proportional hazards regression analysis were performed to identify independent predictors for postoperative complications and survival, respectively.

RESULTS

A total of 310 patients with colorectal cancer with GLIM-defined malnutrition were included, of which 145 (46.77%) were identified with sarcopenia. Malnutritional patients with sarcopenia had significantly higher incidences of total complications (34.5% versus 15.8%), severe complications (9.7% versus 1.8%), longer lengths of postoperative hospital stay (median, 14 days versus 12 days), and more costs (median, 56,257 RMB versus 49,024 RMB) than those without sarcopenia. Sarcopenia was an independent predictive factor for postoperative complications (OR 2.531, 95% CI 1.451-4.415), overall survival (HR 1.519, 95% CI 1.026-2.248), and disease-free survival (HR 1.847, 95% CI 1.324-2.576). Patients with severe sarcopenia had a higher incidence of severe complications but not total complications or survival than those with not-severe sarcopenia. Moreover, the predictive value of sarcopenia for postoperative complications was attributed to muscle strength and quality but not muscle quantity.

CONCLUSION

Sarcopenia predicts postoperative complications and survival in patients with colorectal cancer with GLIM-defined malnutrition. Preoperative assessment of sarcopenia is still necessary when nutritional assessment has been well performed.

Association of Thoracic Skeletal Muscle Index with Clinical Outcome and Response to Nutritional Interventions in Patients at Risk of Malnutrition-Secondary Analysis of a Randomized Trial

BACKGROUND

Measurement of skeletal muscle index (SMI) in computed tomography has been suggested to improve the objective assessment of muscle mass. While most studies have focused on lumbar vertebrae, we examine the association of SMI at the thoracic level with nutritional and clinical outcomes and response to nutritional intervention.

METHODS

We conducted a secondary analysis of EFFORT, a Swiss-wide, multicenter, randomized trial. We investigated the association of low SMI at the 12th thoracic vertebra (T12) with adverse outcome within 30 days after hospital admission (primary endpoint).

RESULTS

663 of 2028 patients from the EFFORT trial had available CT scans for T12, and 519 among them also had available L3 scans. Mean SMI at T12 was 22.4 ± 5.8 cm²/m² and 19.6 ± 5.5 cm²/m² in male and female patients, respectively, and correlated well with nutritional parameters, including nutritional risk based on NRS 2002 (adjusted coefficient -0.63, 95%CI -1.25 to -0.01, p = 0.047), BMI (adjusted coefficient 0.74, 95%CI 0.66 to 0.82, p < 0.001) and handgrip strength (adjusted coefficient 0.15, 95%CI 0.11 to 0.2, p < 0.001). In multivariate regression analyses, low SMI was not a significant predictor for either clinical outcome or for treatment response. Results for SMI measured at L3 were similar, with only little prognostic value.

CONCLUSIONS

Within medical patients at risk for malnutrition, SMI at thoracic vertebra provided low prognostic information regarding clinical outcomes and nutritional treatment response.