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Majeed T, Sharma B, Sharma R, Bodh V, Chauhan A, Surya M, Mir BA, Sharma N, Sharma D. Sarcopenia in cirrhosis: Unraveling the prevalence and relationships with liver disease severity and complications. Indian J Gastroenterol 2024:10.1007/s12664-024-01550-0. [PMID: 38849681 DOI: 10.1007/s12664-024-01550-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 02/01/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND AND OBJECTIVES Sarcopenia in cirrhosis is associated with poor survival and adverse pre and post-transplant outcomes. The study aimed at determining the prevalence of sarcopenia and its association with the severity, complications and etiology of liver disease. METHODS As many as 416 cirrhotic patients who met the inclusion criteria underwent muscle strength testing using a dynamometer. As many as 109 probable sarcopenia patients underwent computed tomography (CT) scan to measure skeletal muscle index (SMI) at the L3 vertebral level and gait-speed testing. The gender-specific cut-offs used to define sarcopenia were an SMI of 36.54 cm2/m2 in males and 30.21 cm2/m2 in females. A gait speed ≤ 0.8 m/s was taken as a cut-off to define severe sarcopenia in both genders. RESULTS The mean age was 54.7 ± 9.51 years and male:female ratio was 2.2:1.The mean body mass index (BMI) was 24.2 ± 1.34 kg/m2. Alcohol and non-alcoholic steatohepatitis (NASH) were the two most common etiologies (45.9% and 31.2%). The proportion of patients belonging to Child-Pugh class A, B and C was 26.6%, 48.6% and 24.8%, respectively. Forty out of 109 (36.7%) patients had a model for end-stage liver disease (MELD) > 14. Ascites, upper gastrointestinal bleeding and hepatic encephalopathy (HE) were present in 59 (54.1%), 60 (55.0%) and 24 (22.0%) patients, respectively. The prevalence of probable sarcopenia, sarcopenia and severe sarcopenia was found to be 26.20%, 10.09% and 6.73%, respectively. Sarcopenia and severe sarcopenia were associated with Child-Pugh class (p < 0.001, p < 0.001), MELD (p = 0.007, 0.002), upper gastrointestinal bleed (p = 0.007, 0.004), ascites (p = 0.038, 0.025) and HE (0.001, < 0.001). CONCLUSION The prevalence of sarcopenia and severe sarcopenia was found to be 10.09% and 6.73%, respectively. Sarcopenia and severe sarcopenia had a significant association with the severity and complications of cirrhosis. However, no association was observed with etiology of liver disease.
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Affiliation(s)
- Tahir Majeed
- Department of Gastroenterology and Hepatology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Brij Sharma
- Department of Gastroenterology and Hepatology, Indira Gandhi Medical College, Shimla, 171 001, India.
| | - Rajesh Sharma
- Department of Gastroenterology and Hepatology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Vishal Bodh
- Department of Gastroenterology and Hepatology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Ashish Chauhan
- Department of Gastroenterology and Hepatology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Mukesh Surya
- Department of Radio-Diagnosis and Imaging, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Bilal Ahmad Mir
- Department of Gastroenterology and Hepatology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Neetu Sharma
- Department of Physiology, Indira Gandhi Medical College, Shimla, 171 001, India
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Yang Y, Eguchi A, Mori C, Hashimoto K. Dietary sulforaphane glucosinolate mitigates depression-like behaviors in mice with hepatic ischemia/reperfusion injury: A role of the gut-liver-brain axis. J Psychiatr Res 2024; 176:129-139. [PMID: 38857554 DOI: 10.1016/j.jpsychires.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/16/2024] [Accepted: 06/04/2024] [Indexed: 06/12/2024]
Abstract
Nutrition has been increasingly recognized for its use in mental health. Depression is commonly observed in patients with chronic liver disease (CLD). Building on our recent findings of depression-like behaviors in mice with hepatic ischemia/reperfusion (HI/R) injury, mediated by the gut-liver-brain axis, this study explored the potential influence of dietary sulforaphane glucosinolate (SGS) on these behaviors. Behavioral assessments for depression-like behaviors were conducted 7 days post either sham or HI/R injury surgery. Dietary intake of SGS significantly prevented splenomegaly, systemic inflammation, depression-like behaviors, and downregulation of synaptic proteins in the prefrontal cortex (PFC) of HI/R-injured mice. Through 16S rRNA analysis and untargeted metabolomic analyses, distinct bacterial profiles and metabolites were identified between control + HI/R group and SGS + HI/R group. Correlations were observed between the relative abundance of gut microbiota and both behavioral outcomes and blood metabolites. These findings suggest that SGS intake could mitigate depression-like phenotypes in mice with HI/R injury, potentially through the gut-liver-brain axis. Additionally, SGS, found in crucial vegetables like broccoli, could offer prophylactic nutritional benefits for depression in patients with CLD.
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Affiliation(s)
- Yong Yang
- Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, Chiba, 260-8670, Japan; Department of Neurosurgery, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Akifumi Eguchi
- Department of Sustainable Health Science, Chiba University Center for Preventive Medical Sciences, Chiba, 263-8522, Japan
| | - Chisato Mori
- Department of Sustainable Health Science, Chiba University Center for Preventive Medical Sciences, Chiba, 263-8522, Japan; Department of Bioenvironmental Medicine, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan
| | - Kenji Hashimoto
- Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, Chiba, 260-8670, Japan.
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Correia J, Estevinho MM, Mesquita P, Gomes LC, Silva AP, Fernandes S, Rodrigues J, Afecto E, Freitas T. Are sarcopenia, frailty and malnutrition prognostic markers of liver disease decompensation in the ambulatory setting? - A prospective cohort study. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:250-257. [PMID: 38095223 DOI: 10.17235/reed.2023.9907/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
BACKGROUND sarcopenia, frailty and malnutrition are associated with adverse outcomes in liver cirrhosis. Studies assessing the prognostic value of these conditions in ambulatory patients with cirrhosis are scarce. METHODS a prospective cohort study was performed, with consecutive inclusion of all patients with cirrhosis observed in the Hepatology outpatient clinic of a Portuguese tertiary center. At study enrolment, evaluation of muscle mass (ultrasound quadriceps femoris thickness), muscle strength (handgrip dynamometry) and nutritional status (Patient-Generated Subjective Global Assessment Short Form) were performed. Follow-up ended upon the occurrence of a composite endpoint, comprising of liver decompensation events and liver-related death, or last medical appointment/non-liver related death before the end of the study. The prognostic value of anthropometrical parameters and nutritional status in the composite endpoint was assessed using a multivariate Cox regression analysis, adjusted for several confounders. RESULTS ninety patients were enrolled (80 % male), with a mean age of 63.5 ± 10.5 years. The median follow-up was 30 (interquartile range 38) weeks, during which, 12 patients reached the composite endpoint. These patients presented a lower mean handgrip strength (23.1 ± 6.41 vs 30.3 ± 10.4 kg, p = 0.04) compared to patients who did not reach the composite endpoint. However, Cox regression multivariate analysis did not find any independent predictors of the composite endpoint, apart from previous decompensation episodes. CONCLUSION in this study, muscle strength was lower in the group of patients with cirrhosis who presented a liver-related event. Handgrip strength might be a promising tool in the ambulatory setting to identify patients at risk of liver decompensation and liver-related death in the short term.
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Affiliation(s)
- João Correia
- Gastrenterology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal
| | | | - Pedro Mesquita
- Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho
| | - Luís Correia Gomes
- Gastroenterology, Instituto Português de Oncologia de Lisboa Francisco Gentil
| | - Ana Paula Silva
- Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho
| | - Sónia Fernandes
- Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho
| | - Jaime Rodrigues
- Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho
| | - Edgar Afecto
- Gastroenterology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal
| | - Teresa Freitas
- Gastroenterology, Centro Hospitalar Vila Nova de Gaia/Espinho
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Singla N, Inavolu P, Kumar BR, Macherla R, Reddy DN. SARC-F Score: A Quick Bedside Tool to Screen Sarcopenia in Patients With Cirrhosis. J Clin Exp Hepatol 2024; 14:101318. [PMID: 38261819 PMCID: PMC10792645 DOI: 10.1016/j.jceh.2023.101318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 12/07/2023] [Indexed: 01/25/2024] Open
Abstract
Background Sarcopenia is often ignored in clinical practice despite being an important prognostic marker. SARC-F is a simple bedside score to assess muscle abnormalities in cirrhosis patients. However, there is limited Indian data on the validity of this score. Hence, we aimed to assess the validity of SARC-F score in a tertiary care center. Methods A prospective observational study including consecutive 100 cirrhosis patients attending the gastroenterology outpatient department in Osmania Medical College and Hospital, Hyderabad, India, was conducted from Jan 2018 to Dec 2019. The primary aim was to assess the mean muscle volume loss (MVL) by computed tomography and handgrip (HG) strength for muscle strength decline (MSD) and compare the SARC-F score with standard cut-off values. Results We included 100 cirrhosis patients (mean age: 45 years; males: 86%; child-pugh class B/C: 42/58). Sixty-nine percent of the patients had a SARC-F score of ≥4, whereas MVL and MSD were noted in 62% and 86% patients, respectively. Mid-arm circumference, skin-fold thickness, mid-arm muscle circumference (MAMC), and HG strength were significantly lower in patients with SARC-F score ≥4 than in those with SARC-F score <4 (P < 0.05). The Pearson correlation plot suggested a significant inverse correlation between the SARC-F score and MSD and SARC-F score and MVL. A SARC-F score of ≥4 had a sensitivity and specificity of 80.7% and 50% for MVL and 75.6% and 71.4% for MSD, respectively, whereas it was 83.3% and 52.5% for MSD and MVL combined, respectively. Area under the receiver operating characteristic curve for SARC-F as a predictor of MVL was 0.75 (95% confidence interval: 0.64-0.82; P=<0.001). On multivariate analysis, a high SARC-F score and low MAMC were predictive of MVL in cirrhosis patients. Conclusion SARC-F score has good sensitivity as a bedside screening tool for sarcopenia in patients with cirrhosis. A high SARC-F score and low MAMC indicates the presence of MVL and warrants further evaluation for sarcopenia.
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Affiliation(s)
- Neeraj Singla
- Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Pradev Inavolu
- Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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Geladari E, Alexopoulos T, Vasilieva L, Tenta R, Kontogianni M, Alexopoulou A. Letter: Severe underweight and sarcopenia in decompensated cirrhosis are associated with high FGF21 levels. Aliment Pharmacol Ther 2024; 59:795-796. [PMID: 38401142 DOI: 10.1111/apt.17881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/05/2024] [Indexed: 02/26/2024]
Abstract
LINKED CONTENTThis article is linked to Alkhouri et al papers. To view these articles, visit https://doi.org/10.1111/apt.17709 and https://doi.org/10.1111/apt.17907
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Affiliation(s)
- Eleni Geladari
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Theodoros Alexopoulos
- Gastroenterology Department, National & Kapodistrian University of Athens, Medical School, Laiko General Hospital, Athens, Greece
| | | | - Roxane Tenta
- Department of Nutrition and Dietetics, School of Health Sciences & Education, Harokopio University of Athens, Athens, Greece
| | - Meropi Kontogianni
- Department of Nutrition and Dietetics, School of Health Sciences & Education, Harokopio University of Athens, Athens, Greece
| | - Alexandra Alexopoulou
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
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Jatin Y, Sharma S, Singh N, Qamar S, Agarwal S, Gopi S, Gunjan D, Saraya A. An Open-label Randomized Controlled Trial of Early Initiation of Nasogastric Feeding After Endotherapy in Variceal Bleeding: A Proof-of-concept Study. J Clin Exp Hepatol 2024; 14:101260. [PMID: 38076376 PMCID: PMC10709198 DOI: 10.1016/j.jceh.2023.07.413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/22/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND AND AIMS Limited data exist on the safety of early nasogastric (NG) feeding in patients with cirrhosis after endotherapy for variceal bleeding (VB). We studied the impact of early NG tube feeding in these patients in this proof-of-concept open-label randomized controlled trial. METHODS Eligible patients with cirrhosis undergoing endotherapy for VB were randomized to receive either a liquid diet through a 14 Fr NG tube (commencing 1 h after endotherapy) (early feeding [EF] group) or sips of water and lemon water orally (standard-of-care [SOC] group) for total duration of 48 h. The primary outcome was 5-day rebleeding in both arms. Other outcomes included 5-day infection rate, hepatic encephalopathy during hospitalization, and 6-week mortality. RESULTS Eighty patients (Mean age: 41 ± 11.5 years; males [82.5%]; alcohol etiology [55%]) were included. Baseline median Child-Pugh and MELD scores were similar (CTP: 8 [IQR: 8-9] vs 9 [8-9.25]; P = 0.47 and MELDNa: 13 [10.75-16.25] vs 15 [12-18.25]; P = 0.16). The 5-day rebleeding rates in EF and SOC groups were 2.5% and 5%, respectively (P = 0.55), and non-inferiority or superiority of either could not be demonstrated. The incidence of infection (2.5% [EF] vs 2.5% [SOC]; P = 1.00) and development of HE (5% [EF] vs 2.5% [SOC]; P = 0.36) during hospitalization were comparable. The average daily calorie and protein intake in the EF group during the 48 h was 1318 ± 240 Kcals and 43.4 ± 9.2 g of proteins. No patient in the EF group had feed intolerance. CONCLUSION Early initiation of NG tube-based feeding after endotherapy in VB appears safe and well tolerated without the additional risk of rebleeding or encephalopathy.
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Affiliation(s)
- Yegurla Jatin
- All India Institute of Medical Sciences, New Delhi, India
| | - Sanchit Sharma
- All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Singh
- All India Institute of Medical Sciences, New Delhi, India
| | - Sumaira Qamar
- All India Institute of Medical Sciences, New Delhi, India
| | | | - Srikanth Gopi
- All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- All India Institute of Medical Sciences, New Delhi, India
| | - Anoop Saraya
- All India Institute of Medical Sciences, New Delhi, India
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Ferenc K, Jarmakiewicz-Czaja S, Filip R. What Does Sarcopenia Have to Do with Nonalcoholic Fatty Liver Disease? Life (Basel) 2023; 14:37. [PMID: 38255652 PMCID: PMC10820621 DOI: 10.3390/life14010037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/11/2023] [Accepted: 12/16/2023] [Indexed: 01/24/2024] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease. As the second stage of developing steatosis, nonalcoholic hepatitis (NASH) carries the risk of fibrosis, cirrhosis, and hepatocellular carcinoma. Sarcopenia is defined as a condition characterized by a decrease in muscle mass and functional decline. Both NAFLD and sarcopenia are global problems. The pathophysiological mechanisms that link the two entities of the disease are insulin resistance, inflammation, nutritional deficiencies, impairment of myostatin and adiponectin, or physical inactivity. Furthermore, disorders of the gut-liver axis appear to induce the process of developing NAFLD and sarcopenia. The correlations between NAFLD and sarcopenia appear to be bidirectional, so the main objective of the review was to determine the cause-and-effect relationship between the two diseases.
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Affiliation(s)
- Katarzyna Ferenc
- Institute of Medicine, Medical College of Rzeszow University, 35-959 Rzeszow, Poland;
| | | | - Rafał Filip
- Institute of Medicine, Medical College of Rzeszow University, 35-959 Rzeszow, Poland;
- Department of Gastroenterology with IBD Unit, Clinical Hospital No. 2, 35-301 Rzeszow, Poland
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Thyloor Kenchappa S, Sharma S, Kumar M, Ghuman SS, Arora A, Ranjan P. A Prospective Study of Prevalence and Impact of Sarcopenia on Short-term Mortality in Hospitalized Patients with Liver Cirrhosis. J Clin Exp Hepatol 2023; 13:946-954. [PMID: 37975055 PMCID: PMC10643475 DOI: 10.1016/j.jceh.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 05/01/2023] [Indexed: 11/19/2023] Open
Abstract
Background Sarcopenia is common in chronic advanced liver disease and is associated with poor prognosis. There is paucity of Indian data regarding sarcopenia in chronic advanced liver disease & its impact on prognosis. The aim of this study was to study the prevalence of sarcopenia in Indian patients with chronic advanced liver disease and its impact on morbidity and short-term mortality. Methods Patients with chronic advanced liver disease were prospectively evaluated for the presence of sarcopenia using computerized tomography (CT) abdomen. The cross-sectional area of the right psoas muscle was measured at the third lumbar vertebra (L3) and the Psoas muscle index (PMI) was calculated. Sarcopenia was defined as PMI <295 mm2/m2 for females and <356 mm2/m2 for males. The normative values of PMI were obtained from patients undergoing CT scan for non-specific abdominal pain who had no confounding factor which could result in sarcopenia. All patients were followed up for 6 months or until death, whichever was earlier. The impact of sarcopenia on mortality and rate of readmission has been assessed at the end of 6 months. Results Of the 156 patients with chronic advanced liver disease, 74 (47.4%) patients had sarcopenia. Sarcopenia was more commonly seen in males (M: F = 61:13) and in patients with alcohol-related liver disease. There was a linear correlation (negative) between the PMI and severity of liver disease as assessed by Child-Pugh and model for end-stage liver disease (MELD) scores (r = -0.591 and -0.465, respectively). Patients with encephalopathy, ascites, and coagulopathy had higher prevalence of sarcopenia. On six months follow-up, sarcopenic patients had higher readmission rates (74.3% vs. 22%; P = 0.0001) and higher mortality (24.3% vs. 3.7%; P = 0.002). MELD score and PMI were independent predictors of mortality. The cut-off value of PMI 305.9 mm2/m2 predicted mortality with a sensitivity of 76.2% and a false positivity of 22.2% (area under curve was 0.805; 95% confidence interval: 0.69-0.91, P = 0.001). Conclusion Sarcopenia is seen in about half of the patients with chronic advanced liver disease. It is commoner in males, patients with alcoholic liver disease, and those with advanced liver disease. Patients with sarcopenia have worse prognosis, require more frequent hospitalization and it negatively impacts short-term survival.
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Affiliation(s)
| | - Samarth Sharma
- Institute of Liver, Gastroenterology, and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Mandhir Kumar
- Institute of Liver, Gastroenterology, and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Anil Arora
- Institute of Liver, Gastroenterology, and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Piyush Ranjan
- Institute of Liver, Gastroenterology, and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
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Mancell S, Manwani K, Dhawan A, Whelan K. Medium-chain triglycerides and the impact on fat absorption, growth, nutritional status and clinical outcomes in children with cholestatic liver disease: A scoping review. Clin Nutr 2023; 42:2159-2172. [PMID: 37776587 DOI: 10.1016/j.clnu.2023.09.010] [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: 04/14/2023] [Revised: 08/16/2023] [Accepted: 09/10/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND & AIMS Medium-chain triglyceride (MCT) supplementation is recommended in cholestatic liver disease, despite unclear evidence and no consensus on the ideal percentage of fat that should be MCT. The aim was to undertake a scoping review to identify the extent and type of evidence regarding how MCT supplementation, and percentage of MCT, affects fat absorption, growth, nutritional status and clinical outcomes (morbidity, mortality, transplant) in children with cholestatic liver disease. METHODS Nine databases (MEDLINE, Embase, CINAHL, PubMed, AMED, Cochrane Library, Global Health, Scopus, Proquest) were searched from inception, with hand-searching conference abstracts and forward/backward citation searching. Eligible studies investigated oral/enteral MCT supplementation in children under 18y with cholestatic liver disease. There were no language limits. Two reviewers performed screening and data extraction independently. Data were synthesised narratively. RESULTS Following title/abstract screening (1202 studies) and full-text review (40 studies), 24 studies were included comprising three small RCTs (n = 19 patients), one non-randomised controlled trial (n = 2), seven uncontrolled trials (n = 83) and thirteen case series/reports (n = 211). Seventeen studies were published before 1994. Outcomes included absorption, growth and nutritional status. MCT supplementation was associated with greater fat absorption (9/9 studies) and improved growth in some children (2/4). Higher percentage MCT was associated with greater magnesium and calcium absorption (1/1), essential fatty acid (EFA) deficiency (4/4), but not growth (3/3). CONCLUSIONS The limited, mostly observational evidence from >30 years ago points to greater fat absorption on MCT and EFA deficiency on very high percentage MCT. High quality RCTs are required, particularly examining the impact of MCT at different percentages on growth, nutritional status and clinical outcomes.
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Affiliation(s)
- Sara Mancell
- Department of Nutritional Sciences, King's College London, London, UK; Department of Nutrition & Dietetics, King's College Hospital NHS Foundation Trust, London, UK.
| | - Karishma Manwani
- Department of Nutrition & Dietetics, King's College Hospital NHS Foundation Trust, London, UK
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition, King's College Hospital NHS Foundation Trust, London, UK
| | - Kevin Whelan
- Department of Nutritional Sciences, King's College London, London, UK
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Ramachandran G, Pottakkat B, Basu S, Mohan P. Effect of probiotics on nutritional status, biochemical parameters, and disease severity in cirrhotic patients referred for liver transplantation-A randomised double blind, placebo-controlled trial. Clin Nutr ESPEN 2023; 57:703-710. [PMID: 37739726 DOI: 10.1016/j.clnesp.2023.08.021] [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: 04/05/2023] [Revised: 08/12/2023] [Accepted: 08/19/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION Probiotics have been shown to be effective in many diseases. However, their effects on the nutritional status in patients with cirrhosis is uncertain. AIM We aimed to study the effect of probiotics on nutritional status, biochemical parameters, and liver disease severity in patients with cirrhosis referred for liver transplantation. METHODS A randomised, double-blind, placebo-controlled study was conducted from July 2021-October 2022. A total of 215 patients with cirrhosis referred for liver transplantation were enrolled and randomised to two groups to receive either probiotics (VSL#3, Sun Pharma, India, 112.5 billion colony-forming units (cfu) containing eight strains of bacteria) or placebo (corn starch filled capsules), two capsules/day for six weeks. Nutritional assessment was done, and biochemical parameters were measured before and after the intervention. RESULTS Nutritional assessment parameters like body mass index (p = 0.001), triceps skin fold thickness (p = 0.011), muscle strength (p = 0.007) and subjective global assessment scores (p < 0.000) showed a positive trend in the probiotic group. Probiotic intake also significantly downregulated direct bilirubin levels (p = 0.043) and increased albumin levels compared to baseline, but other biochemical parameters remained unchanged. Child Turcotte Pugh score also decreased significantly compared to pre therapy (p = 0.0001). These changes were not observed in the placebo group. Moreover, probiotic VSL#3 supplementation was safe and well-tolerable without any adverse events in patients with cirrhosis. CONCLUSION Probiotic VSL#3 supplementation improved the nutritional status, reduced the severity of liver disease and was safe and tolerable in patients with cirrhosis. TRIAL REGISTRATION www.ctri.nic.in (CTRI/2021/07/034917).
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Affiliation(s)
- Gokulapriya Ramachandran
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, 605006, India.
| | - Biju Pottakkat
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, 605006, India.
| | - Sharbari Basu
- Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, 605006, India
| | - Pazhanivel Mohan
- Department of Medical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Puducherry, 605006, India
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Mishra S, Premkumar M. Nutritional Management of a Liver Transplant Candidate. J Clin Exp Hepatol 2023; 13:878-894. [PMID: 37693267 PMCID: PMC10483011 DOI: 10.1016/j.jceh.2023.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/28/2023] [Indexed: 09/12/2023] Open
Abstract
Nearly two-thirds of patients with cirrhosis suffer from malnutrition resulting from multiple contributory factors such as poor intake, accelerated starvation, catabolic milieu, and anabolic resistance. Nutritional assessment and optimization are integral to adequate management of a liver transplant (LT) candidate. A detailed nutritional assessment should be done at baseline in all potential transplant candidates with periodic reassessments. Sarcopenia is defined as a reduction in muscle mass, function, and/or performance. Skeletal muscle index at 3rd lumbar vertebra determined by computed tomography is the most objective tool to assess muscle mass. Hand-grip strength and gait speed are simple tools to gauge muscle strength and performance, respectively. Sarcopenia, sarcopenic obesity, and myosteatosis portend poor outcomes. Sarcopenia contributes greatly to frailty, which is a syndrome of reduced physiological reserve and impaired response to stressors. Dietary interventions must ensure adequate calorie (35-40 kcal/kg/day) and protein (1.2-1.5 gm/kg/day) intake via multiple frequent meals and late-evening calorie-dense snack. Micronutrient supplementation is essential, keeping in mind the etiology of cirrhosis. Individualized, gradually up-titrated exercise prescription consisting of both aerobic and resistance training of 150 min/week is advisable after appropriate risk assessment. Early initiation of enteral nutrition within 12-24 h of LT is recommended. Data with respect to immune-nutrition, monomeric formulas, and hormone replacement remain conflicting at present. A multidisciplinary team comprising of hepatologists, transplant surgeons, intensivists, dieticians, and physiotherapists is vital to improve overall nutrition and outcomes in this vulnerable group.
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Affiliation(s)
- Saurabh Mishra
- Department of Gastroenterology and Hepatology, Paras Health, Sector-22, Panchkula, Haryana, 134109, India
| | - Madhumita Premkumar
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India
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12
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Janota B, Krupowicz A, Noras K, Janczewska E. Evaluation of the nutritional status of patients with liver cirrhosis. World J Hepatol 2023; 15:914-924. [PMID: 37547031 PMCID: PMC10401412 DOI: 10.4254/wjh.v15.i7.914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/30/2023] [Accepted: 07/04/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Progressive malnutrition coexists with liver diseases, particularly in patients with cirrhosis. Early diagnosis of malnutrition in patients with advanced stages of chronic liver disease and the implementation of appropriate nutritional treatment for malnourished patients should be an integral part of the therapeutic process.
AIM To evaluate the nutritional status of patients with various severities of advanced liver fibrosis, using various nutritional status parameters.
METHODS This study involved 118 patients with liver cirrhosis who were classified into three groups according to their Child-Pugh score. The nutritional status of the patients in each group was assessed using different methods. The average values obtained from the measurements were calculated for each research group. The influence of disease stage on the examined parameters of nutritional status was determined using one-way analysis of variance. To investigate the relationship between the parameters determining nutritional status and the stage of disease advancement, a correlation analysis was performed.
RESULTS The Child-Pugh A group had the highest mean body weight (76.42 kg), highest mean body mass index (BMI) (26.72 kg/m²), and largest mean arm circumference (27.64 cm). In the Child-Pugh B group, the mean scores of all examined variables were lower than those of the Child-Pugh A group, whereas the mean body weight and BMI of the Child-Pugh C group were higher than those of the Child-Pugh B group. There was a very strong correlation between the Child-Pugh classification and subjective global assessment score; a very strong correlation between the Child-Pugh classification and arm circumference; a strong correlation between the Child-Pugh classification and body weight, albumin concentration, fat-free mass index, muscle mass index, phase angle, and BMI; and an average correlation between Child-Pugh classification and fat mass index. Notably, these indicators deteriorated with disease progression.
CONCLUSION Advanced liver fibrosis leads to the deterioration of many nutritional status parameters. The extent of malnutrition increases with the progression of liver fibrosis. The Child-Pugh score reflects the nutritional status.
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Affiliation(s)
- Barbara Janota
- Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia in Katowice, Bytom 41-902, Poland
| | | | - Kinga Noras
- Department of Biometry, Warsaw University of Life Sciences, Warsaw 02-787, Poland
| | - Ewa Janczewska
- Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia in Katowice, Bytom 41-902, Poland
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13
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Trillos-Almanza MC, Wessel H, Martínez-Aguilar M, van den Berg EH, Douwes RM, Moshage H, Connelly MA, Bakker SJL, de Meijer VE, Dullaart RPF, Blokzijl H. Branched Chain Amino Acids Are Associated with Physical Performance in Patients with End-Stage Liver Disease. Biomolecules 2023; 13:biom13050824. [PMID: 37238694 DOI: 10.3390/biom13050824] [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: 03/16/2023] [Revised: 05/04/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Decreased circulating branched chain amino acids (BCAA) represent a prominent change in amino acid profiles in patients with end-stage liver disease (ESLD). These alterations are considered to contribute to sarcopenia and hepatic encephalopathy and may relate to poor prognosis. Here, we cross-sectionally analyzed the association between plasma BCAA levels and the severity of ESLD and muscle function in participants of the liver transplant subgroup of TransplantLines, enrolled between January 2017 and January 2020. Plasma BCAA levels were measured by nuclear magnetic resonance spectroscopy. Physical performance was analyzed with a hand grip strength test, 4 m walking test, sit-to-stand test, timed up and go test, standing balance test and clinical frailty scale. We included 92 patients (65% men). The Child Pugh Turcotte classification was significantly higher in the lowest sex-stratified BCAA tertile compared to the highest tertile (p = 0.015). The times for the sit-to-stand (r = -0.352, p < 0.05) and timed up and go tests (r = -0.472, p < 0.01) were inversely correlated with total BCAA levels. In conclusion, lower circulating BCAA are associated with the severity of liver disease and impaired muscle function. This suggests that BCAA may represent a useful prognostic marker in the staging of liver disease severity.
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Affiliation(s)
- Maria Camila Trillos-Almanza
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700RB Groningen, The Netherlands
| | - Hanna Wessel
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700RB Groningen, The Netherlands
| | - Magnolia Martínez-Aguilar
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700RB Groningen, The Netherlands
| | - Eline H van den Berg
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700RB Groningen, The Netherlands
| | - Rianne M Douwes
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700RB Groningen, The Netherlands
| | - Han Moshage
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700RB Groningen, The Netherlands
| | | | - Stephan J L Bakker
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700RB Groningen, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700RB Groningen, The Netherlands
| | - Robin P F Dullaart
- Department of Internal Medicine, Division of Endocrinology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700RB Groningen, The Netherlands
| | - Hans Blokzijl
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700RB Groningen, The Netherlands
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14
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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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15
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Duseja A, Singh S, De A, Madan K, Rao PN, Shukla A, Choudhuri G, Saigal S, Shalimar, Arora A, Anand AC, Das A, Kumar A, Eapen CE, Devadas K, Shenoy KT, Panigrahi M, Wadhawan M, Rathi M, Kumar M, Choudhary NS, Saraf N, Nath P, Kar S, Alam S, Shah S, Nijhawan S, Acharya SK, Aggarwal V, Saraswat VA, Chawla YK. Indian National Association for Study of the Liver (INASL) Guidance Paper on Nomenclature, Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease (NAFLD). J Clin Exp Hepatol 2023; 13:273-302. [PMID: 36950481 PMCID: PMC10025685 DOI: 10.1016/j.jceh.2022.11.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 11/16/2022] [Accepted: 11/29/2022] [Indexed: 03/24/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a major cause of chronic liver disease globally and in India. The already high burden of NAFLD in India is expected to further increase in the future in parallel with the ongoing epidemics of obesity and type 2 diabetes mellitus. Given the high prevalence of NAFLD in the community, it is crucial to identify those at risk of progressive liver disease to streamline referral and guide proper management. Existing guidelines on NAFLD by various international societies fail to capture the entire landscape of NAFLD in India and are often difficult to incorporate in clinical practice due to fundamental differences in sociocultural aspects and health infrastructure available in India. A lot of progress has been made in the field of NAFLD in the 7 years since the initial position paper by the Indian National Association for the Study of Liver on NAFLD in 2015. Further, the ongoing debate on the nomenclature of NAFLD is creating undue confusion among clinical practitioners. The ensuing comprehensive review provides consensus-based, guidance statements on the nomenclature, diagnosis, and treatment of NAFLD that are practically implementable in the Indian setting.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ALD, alcohol-associated liver disease
- ALT, alanine aminotransferase
- APRI, AST-platelet ratio index
- AST, aspartate aminotransferase
- BMI, body mass index
- CAP, controlled attenuation parameter
- CHB, chronic Hepatitis B
- CHC, chronic Hepatitis C
- CK-18, Cytokeratin-18
- CKD, chronic kidney disease
- CRN, Clinical Research Network
- CVD, cardiovascular disease
- DAFLD/DASH, dual etiology fatty liver disease or steatohepatitis
- EBMT, endoscopic bariatric metabolic therapy
- ELF, enhanced liver fibrosis
- FAST, FibroScan-AST
- FIB-4, fibrosis-4
- FLIP, fatty liver inhibition of progression
- FXR, farnesoid X receptor
- GLP-1, glucagon-like peptide-1
- HCC, hepatocellular carcinoma
- INASL, Indian National Association for Study of the Liver
- LAI, liver attenuation index
- LSM, liver stiffness measurement
- MAFLD
- MAFLD, metabolic dysfunction-associated fatty liver disease
- MR-PDFF, magnetic resonance – proton density fat fraction
- MRE, magnetic resonance elastography
- MetS, metabolic syndrome
- NAFL:, nonalcoholic fatty liver
- NAFLD, nonalcoholic fatty liver disease
- NAS, NAFLD activity score
- NASH
- NASH, nonalcoholic steatohepatitis
- NCD, noncommunicable diseases
- NCPF, noncirrhotic portal fibrosis
- NFS, NAFLD fibrosis score
- NHL, non-Hodgkin's lymphoma
- NPCDCS, National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke
- OCA, obeticholic acid
- PPAR, peroxisome proliferator activated receptor
- PTMS, post-transplant metabolic syndrome
- SAF, steatosis, activity, and fibrosis
- SGLT-2, sodium-glucose cotransporter-2
- SWE, shear wave elastography
- T2DM, DM: type 2 diabetes mellitus
- USG, ultrasound
- VAT, visceral adipose tissue
- VCTE, vibration controlled transient elastography
- fatty liver
- hepatic steatosis
- nonalcoholic steatohepatitis
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Affiliation(s)
- Ajay Duseja
- Departmentof Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S.P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, India
| | - Arka De
- Departmentof Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kaushal Madan
- Max Centre for Gastroenterology, Hepatology and Endoscopy, Max Hospitals, Saket, New Delhi, India
| | - Padaki Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GSMC & KEM Hospital, Mumbai, India
| | - Gourdas Choudhuri
- Department of Gastroenterology and Hepato-Biliary Sciences, Fortis Memorial Research Institute, Gurugram, India
| | - Sanjiv Saigal
- Max Centre for Gastroenterology, Hepatology and Endoscopy, Max Hospitals, Saket, New Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Anil Arora
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil C. Anand
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Ashim Das
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Kumar
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Krishnadas Devadas
- Department of Gastroenterology, Government Medical College, Trivandrum, India
| | | | - Manas Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Manav Wadhawan
- Institute of Liver & Digestive Diseases, BLK Super Speciality Hospital, Delhi, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Neeraj Saraf
- Department of Hepatology, Medanta, The Medicity, Gurugram, India
| | - Preetam Nath
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Sanjib Kar
- Department of Gastroenterology and Hepatology, Gastro Liver Care, Cuttack, India
| | - Seema Alam
- Department of PediatricHepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Samir Shah
- Department of Hepatology, Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, Sawai Man Singh Medical College, Jaipur, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Vinayak Aggarwal
- Department of Cardiology, Fortis Memorial Research Institute, Gurugram, India
| | - Vivek A. Saraswat
- Department of Hepatology, Pancreatobiliary Sciences and Liver Transplantation, Mahatma Gandhi University of Medical Sciences and Technology, Jaipur, India
| | - Yogesh K. Chawla
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
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16
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Nutritional support in liver disease - an updated systematic review. Curr Opin Gastroenterol 2023; 39:115-124. [PMID: 36821460 DOI: 10.1097/mog.0000000000000914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW The association of malnutrition and a poor prognosis does not prove that providing nutrition support improves that prognosis. The proof of such efficacy requires its demonstration in well designed and executed randomized trials. A systematic review of 40 such trials in 2014 failed to make such a finding. The purpose of this work is to update that review. RECENT FINDINGS A search of multiple databases identified 12 new trials (3 of enteral nutrition and 9 of nutritional supplements) comparing the nutritional intervention to standard care. Meta-analyses suggested that the provision of enteral nutrition reduced infection rates in patients undergoing liver transplantation and total complication rates after hepatic resections. Supplement usage appeared to improve mortality in patients with hepatocellular carcinoma or transplanted livers and reduce rates of ascites in patients with cirrhosis and hepatocellular carcinoma as well as improve encephalopathy resolution in those with cirrhosis. However, the risks of bias, some study designs, and the use of potentially pharmacologically active micronutrients limit the reliability of these observations. SUMMARY There is inadequate evidence for clinicians to be sure that nutrition support is actually of benefit to patients with liver disease.
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17
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Rodge GA, Goenka U, Jajodia S, Agarwal R, Afzalpurkar S, Roy A, Goenka MK. Psoas Muscle Index: A Simple and Reliable Method of Sarcopenia Assessment on Computed Tomography Scan in Chronic Liver Disease and its Impact on Mortality. J Clin Exp Hepatol 2023; 13:196-202. [PMID: 36950487 PMCID: PMC10025677 DOI: 10.1016/j.jceh.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/02/2022] [Indexed: 03/24/2023] Open
Abstract
Objectives Psoas muscle parameters have been proposed as a simple and quick method for sarcopenia assessment. The aim of this study was to assess sarcopenia in cirrhotics by psoas muscle on computed tomography and its impact on mortality. Methods One hundred and fifty patients (75 cirrhotics, 75 subjects) were assessed for psoas muscle on CT scan. Psoas muscle index (PMI) was calculated as 'total psoas muscle area/(height of subject)2'. Cut off values for sarcopenia diagnosis were derived from local subjects (n = 75) who did not have cirrhosis/other causes of sarcopenia. Results Sarcopenia assessed by PMI was seen in 36% (n = 27) of the cirrhotics. Sarcopenia was significantly higher in patients having Child-Pugh C. Ascites, hepatic encephalopathy (HE) and gastro-intestinal bleed were seen in 48%, 18.7% and 24%, respectively. Sarcopenia was significantly associated with ascites and HE (P < 0.05). Out of the 75 cases, 53 cases completed the follow-up period of 1 year. Among the 20 cases who had sarcopenia, 35% (n = 7) succumbed to liver-related illness during 1 year follow-up, and out of the 33 cases without sarcopenia, only 6% (n = 2) died. The association of sarcopenia and 1 year mortality was statistically significant (P = 0.01). Conclusions The PMI, a simple method for sarcopenia assessment detected sarcopenia in 36% of cirrhotics. Patients with sarcopenia had a significantly higher 1 year mortality rate and appropriate prognostication of such patients is needed.
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Key Words
- CLD, Chronic Liver Disease
- CT scan
- CT, Computed Tomography
- GI, Gastro-Intestinal
- HBV, Hepatitis B Virus
- HCV, Hepatitis C Virus
- HE, Hepatic Encephalopathy
- HG, Hand Grip
- L3SMI
- MAC, Mid-Arm Circumference
- MAMC, Mid-Arm Muscle Circumference
- MELD, Model for End Stage Liver Disease
- NASH, Non-Alcoholic Steato-Hepatitis
- PBC, Primary Biliary Cholangitis
- PMI, Psoas Muscle Index
- PMTH, Psoas Muscle Thickness by Height of subject
- SMI, Skeletal Muscle Index
- TST, Tricep Skin fold Thickness
- chronic liver disease
- psoas muscle index
- sarcopenia
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Affiliation(s)
- Gajanan A. Rodge
- Institute of Gastrosciences & Liver, Apollo Multispeciality Hospital, Kolkata, India
| | - Usha Goenka
- Department of Interventional Radiology & Clinical Imaging, Apollo Multispeciality Hospital, Kolkata, India
| | - Surabhi Jajodia
- Department of Interventional Radiology & Clinical Imaging, Apollo Multispeciality Hospital, Kolkata, India
| | - Rachit Agarwal
- Department of Gastroenterology, Orange City Hospital & Research Hospital, Nagpur, India
| | - Shivaraj Afzalpurkar
- Institute of Gastrosciences & Liver, Apollo Multispeciality Hospital, Kolkata, India
| | - Akash Roy
- Institute of Gastrosciences & Liver, Apollo Multispeciality Hospital, Kolkata, India
| | - Mahesh K. Goenka
- Institute of Gastrosciences & Liver, Apollo Multispeciality Hospital, Kolkata, India
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18
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Kumar R, Prakash SS, Priyadarshi RN, Anand U. Sarcopenia in Chronic Liver Disease: A Metabolic Perspective. J Clin Transl Hepatol 2022; 10:1213-1222. [PMID: 36381104 PMCID: PMC9634780 DOI: 10.14218/jcth.2022.00239] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/14/2022] [Accepted: 07/19/2022] [Indexed: 12/04/2022] Open
Abstract
Sarcopenia, a condition of low muscle mass, quality, and strength, is commonly found in patients with chronic liver disease (CLD) and is associated with adverse clinical outcomes including reduction in quality of life, increased mortality, and complications. A major contributor to sarcopenia in CLD is the imbalance in muscle protein turnover wherein changes in various metabolic factors such as hyperammonemia, amino acid deprivation, hormonal imbalance, gut dysbiosis, insulin resistance, chronic inflammation, etc. have important roles. In particular, hyperammonemia is a key mediator of the liver-gut axis and is known to contribute to sarcopenia by various mechanisms including increased expression of myostatin, increased phosphorylation of eukaryotic initiation factor 2a, cataplerosis of α-ketoglutarate, mitochondrial dysfunction, increased reactive oxygen species that decrease protein synthesis and increased autophagy-mediated proteolysis. Skeletal muscle is a major organ of insulin-induced glucose metabolism, and sarcopenia is closely linked to insulin resistance and metabolic syndrome. Patients with liver cirrhosis are in a hypermetabolic state that is associated with catabolism and depletion of amino acids, particularly branched-chain amino acids. Sarcopenia can have significant implications for nonalcoholic fatty liver disease, the most common form of CLD worldwide, because of the close link between metabolic syndrome and sarcopenia. This review discusses the potential metabolic derangement as a cause or effect of sarcopenia in CLD, as well as interorgan crosstalk, which that might help identifying a novel therapeutic strategies.
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, India
- Correspondence to: Ramesh Kumar, Department of Gastroenterology, fourth floor, OPD Block, All India Institute of Medical Sciences, Patna 801507, India. ORCID: https://orcid.org/0000-0001-5136-4865. Tel: +91-7765803112, Fax: +91-11-26588663, E-mail:
| | - Sabbu Surya Prakash
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | | | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
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19
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Nath P, Anand AC. Extrahepatic Manifestations in Alcoholic Liver Disease. J Clin Exp Hepatol 2022; 12:1371-1383. [PMID: 36157144 PMCID: PMC9499846 DOI: 10.1016/j.jceh.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/20/2022] [Indexed: 12/12/2022] Open
Abstract
Though liver is the most commonly affected organ in patients with chronic and excessive intake of alcohol, no organ is immune to toxic effects of alcohol and patients with alcohol-related liver disease (ALD) can suffer from a wide list of extrahepatic manifestations involving gastrointestinal tract, central and peripheral nervous systems, cardio vascular system, musculo-skeletal system, disruption of nutritional status, endocrinological abnormalities, hematological abnormalities and immune dysfunction. These extrahepatic organ involvements are usually overlooked by hepatologists and physicians who are mostly focused on managing life threatening complications of ALD. As a result, there is delayed diagnosis, delay in the initiation of appropriate treatment and late referral to other specialists. Some of these manifestations are of utmost clinical importance (e.g. delirium tremans and Wernicke's encephalopathy) because an early diagnosis and treatment can lead to full recovery while delayed or no treatment can result in death. On the other hand, several extrahepatic manifestations are of prognostic significance (such as alcoholic cardiomyopathy and malignancies) in which there is an increased risk of morbidity and mortality. Hence, a clear understanding and awareness of the extrahepatic manifestations of ALD is quintessential for proper management of these patients.
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Key Words
- ACE, Angiotensin-Converting-Enzyme
- ALD, Alcohol related Liver Disease
- AUD, Alcohol Use Disorder
- GAVE, Gastric Antral Vascular Ectasia
- GERD, Gastro-Esophageal Reflux Disease
- HCC, Hepatocellular Carcinoma
- HIV, Human Immunodeficiency Virus
- IARC, International Agency for Research on Cancer
- IL, Interleukin
- NERD, Non-Erosive Reflux Disease
- PPI, Proton Pump Inhibitors
- TNF, Tumour Necrosis Factor
- UGI, Upper Gastrointestinal
- WHO, World Health Organization
- alcohol use disorder
- alcohol withdrawal syndrome
- alcoholic cardiomyopathy
- alcoholic liver disease
- alcoholic myopathy
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Affiliation(s)
- Preetam Nath
- Department of Gastroenterology & Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, 751024, India
| | - Anil C. Anand
- Department of Gastroenterology & Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, 751024, India
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Ayares G, Idalsoaga F, Díaz LA, Arnold J, Arab JP. Current Medical Treatment for Alcohol-Associated Liver Disease. J Clin Exp Hepatol 2022; 12:1333-1348. [PMID: 36157148 PMCID: PMC9499849 DOI: 10.1016/j.jceh.2022.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/06/2022] [Indexed: 12/12/2022] Open
Abstract
Alcohol-associated liver disease is one of the main causes of chronic liver disease. It comprises a clinical-histologic spectrum of presentations, from steatosis, steatohepatitis, to different degrees of fibrosis, including cirrhosis and severe necroinflammatory disease, called alcohol-associated hepatitis. In this focused update, we aim to present specific therapeutic interventions and strategies for the management of alcohol-associated liver disease. Current evidence for management in all spectra of manifestations is derived from general chronic liver disease recommendations, but with a higher emphasis on abstinence and nutritional support. Abstinence should comprise the treatment of alcohol use disorder as well as withdrawal syndrome. Nutritional assessment should also consider the presence of sarcopenia and its clinical manifestation, frailty. The degree of compensation of the disease should be evaluated, and complications, actively sought. The most severe acute form of this disease is alcohol-associated hepatitis, which has high mortality and morbidity. Current treatment is based on corticosteroids that act by reducing immune activation and blocking cytotoxicity and inflammation pathways. Other aspects of treatment include preventing and treating hepatorenal syndrome as well as preventing infections although there is no clear evidence as to the benefit of probiotics and antibiotics in prophylaxis. Novel therapies for alcohol-associated hepatitis include metadoxine, interleukin-22 analogs, and interleukin-1-beta antagonists. Finally, granulocyte colony-stimulating factor, microbiota transplantation, and gut-liver axis modulation have shown promising results. We also discuss palliative care in advanced alcohol-associated liver disease.
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Key Words
- AC, Amoxicillin/clavulanate
- ACLF, Acute-on-Chronic Liver Failure
- ADLs, Activities of Daily Living
- AH, Alcohol-Associated Hepatitis
- AKI-HRS, Acute Kidney Injury - Hepatorenal Syndrome
- ALD
- ALD, Alcohol-Associated Liver Disease
- ASH, Alcoholic Steatohepatitis
- AUD, Alcohol Use Disorder
- AWS, Alcohol Withdrawal Syndrome
- BCAAs, Branched-Chain Amino Acids
- CDC, Center for Disease Control
- CI, Confidence Interval
- COVID-19, Coronavirus Disease 2019
- CT, Computerized Tomography
- GABA, gamma-aminobutyric acid agonist
- HBV, Hepatitis B Virus
- HCC, Hepatocellular Carcinoma
- HCV, Hepatitis C Virus
- HE, Hepatic Encephalopathy
- HIV, Human Immunodeficiency Virus
- HR, Hazard Ratio
- IBW, Ideal Body Weight
- ICA, International Club of Ascites
- IL-1β, Interleukin-1β
- IL-22, Interleukin-22
- KPS, Karnofsky Performance Status
- LB, Liver Biopsy
- LPS, Lipopolysaccharide
- LSM, Liver Stiffness Measurement
- LT, Liver Transplantation
- MDF, Maddrey’s Discriminant Function
- MELD, Model of End-Stage Liver Disease
- MRI, Magnetic Resonance Imaging
- MUST, Malnutrition Universal Screening Tool
- NIAAA, National Institute on Alcohol Abuse and Alcoholism
- NRS-2002, Nutritional Risk Screening-2002
- OR, Odds Ratio
- PAMPs, Pathogen-Activated Molecular Patterns
- PMI, Psoas Muscle Index
- PTX, Pentoxifylline
- RAI, Relative Adrenal Insufficiency
- RCT, Randomized Clinical Trials
- RFH-NPT, Royal Free Hospital-Nutritional Prioritizing Tool
- ROS, Reactive Oxygen Species
- RR, Relative Risk
- SIRS, Systemic Inflammatory Response Syndrome
- TNF, Tumor Necrosis Factor
- WKS, Wernicke-Korsakoff Syndrome
- alcohol
- alcohol use disorders
- alcohol-associated hepatitis
- cirrhosis
- fatty liver disease
- steatosis
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Affiliation(s)
- Gustavo Ayares
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Idalsoaga
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis A. Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Arnold
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan P. Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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Reshetnyak VI, Maev IV. Mechanism for development of malnutrition in primary biliary cholangitis. World J Meta-Anal 2022. [DOI: 10.13105/wjma.v10.i3.81 reshetnyak vi] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
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Reshetnyak VI, Maev IV. Mechanism for development of malnutrition in primary biliary cholangitis. World J Meta-Anal 2022; 10:81-98. [DOI: 10.13105/wjma.v10.i3.81] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/14/2022] [Accepted: 05/23/2022] [Indexed: 02/06/2023] Open
Abstract
Primary biliary cholangitis (PBC) is a chronic cholestatic liver disease that is associated with impaired biliary excretion processes. Along with the development of cholestasis, there is a deficient flow of bile acids into the intestinal lumen causing malnutrition (MN) that is manifested in deficiencies of both macro- and micronutrients. The mechanism for development of trophological insufficiency is multifactorial. However, the trigger of MN in PBC is impaired enterohepatic circulation of bile acids. The ingress of bile acids with a detergent effect into the general bloodstream, followed by elimination via the kidneys and skin, triggers a cascade of metabolic disturbances, which leads to the gradual development and progression of calorie MN. The latter gradually transforms into protein-calorie MN (PСM) (as marasmus) due to the insufficient entry of bile acids into the duodenum, which is accompanied by a decrease in the emulsification, hydrolysis, and absorption of fats and fat-soluble vitamins, as well as disturbance of intestinal motility and bacterial overgrowth. Fat-soluble vitamin deficiencies complement PСM with vitamin and mineral MN. The development of hepatocellular failure enhances the progression of PСM due to the impaired protein synthetic function of hepatocytes in the advanced stage of PBC, which results in deficiency of not only the somatic but also the visceral pool of proteins. A mixed PСM form of marasmus and kwashiorkor develops. Early recognition of energy, protein, micronutrient, and macronutrient deficiencies is of great importance because timely nutritional support can improve liver function and quality of life in patients with PBC. In this case, it is important to know what type (energy, protein-calorie, vitamin, and vitamin-mineral) and form (marasmus, marasmus-kwashiorkor) of MN is present in the patient and how it is associated with the stage of the disease. Therefore, it is recommended to screen all patients with PBC for MN, from the early asymptomatic stage of the disease in order to identify and avoid preventable complications, such as fatigue, malaise, performance decrement, sarcopenia, osteoporosis, and hepatic encephalopathy, which will be able to provide appropriate nutritional support for correction of the trophological status.
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Affiliation(s)
- Vasiliy Ivanovich Reshetnyak
- Department of Propaedeutic of Internal Diseases and Gastroenterology, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow 127473, Russia
| | - Igor Veniaminovich Maev
- Department of Propaedeutic of Internal Diseases and Gastroenterology, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow 127473, Russia
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Hand-grip strength as a screening tool for sarcopenia in males with decompensated cirrhosis. Indian J Gastroenterol 2022; 41:284-291. [PMID: 35852763 DOI: 10.1007/s12664-022-01255-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 02/22/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Skeletal muscle index (SMI), the gold standard for sarcopenia, cannot measure muscle strength and requires specialized software and training. Hand-grip strength (HGS) measurement is cheap, requires minimal training and directly reflects muscle strength. We assessed the performance of HGS as a screening tool for sarcopenia in male patients with decompensated cirrhosis (DC). METHODS Consecutive male DC patients (n=155) were enrolled. Baseline liver functions, etiologic work-up and anthropometric measurements were done. SMI was determined from computed tomography (CT) images at L3 level using ImageJ software. Sarcopenia was diagnosed using SMI cut-off <42 cm2/m2 as suggested by the Indian National Association for Study of the Liver. HGS was assessed using a hand-grip dynamometer. Diagnostic performance of HGS for discriminating sarcopenia was described using receiver operating characteristic (ROC) analysis. Diagnostic performance of different HGS cut-offs was assessed. Findings were internally validated using bootstrapping. RESULTS Mean HGS and SMI were 25.73 ± 5.94 kg and 47.72 ± 8.71 cm2/m2, respectively. HGS showed modest correlation with SMI (tau: 0.31, p <0.001). Sarcopenia was seen in 41 (26.5%) patients. Age and HGS were independent predictors of sarcopenia on multivariate analysis. Area under the ROC curve (AUROC) of HGS for detecting sarcopenia was 0.73 (p<0.001). Optimal cut-off for using HGS as a screening tool was ≤31 kg (sensitivity: 37/41 [90.2%]; specificity: 29/114 [25.4%]; positive predictive value [PPV] : 37/122 [30.3%]; and negative predictive value [NPV]: 29/33 [87.9%]). CONCLUSION Prevalence of sarcopenia in Indian male patients with DC is 26.5%. HGS is an independent predictor of sarcopenia and can be used as a screening tool to stratify the need for confirmatory CT-based assessment of sarcopenia.
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Saraswat VA, Kumar K. Untangling the Web of Malnutrition, Sarcopenia, and Frailty in Chronic Liver Disease. J Clin Exp Hepatol 2022; 12:268-271. [PMID: 35535088 PMCID: PMC9077231 DOI: 10.1016/j.jceh.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Key Words
- 6MWT, 6-minute walk test
- ADL, Activities of Daily Living
- BIA, Bioelectrical Impedance analysis
- BMC, Bone Mineral Content
- CFS, Clinical Frailty Score
- DEXA, dual-energy X-ray absorptiometry
- FFC, Fried Frailty Criteria
- FFM, Fat-Free Mass
- FM, Fat Mass
- HE, hepatic encephalopathy
- KPS, Karnofsky Performance Score
- LFI, Liver Frailty Index
- LM, Lean Mass
- MAMC, mass and mid-arm muscle circumference
- MELD, model for end-stage liver disease
- SMI-L3, skeletal muscle index at the 3rd lumbar vertebra
- SPPB, Short Physical Performance Battery
- TSFT, triceps skinfold thickness
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Affiliation(s)
- Vivek A. Saraswat
- Address for correspondence. Professor Vivek A. Saraswat, Department of Hepatology, Pancreato-biliary Sciences, and Liver Transplantation, Mahatma Gandhi Medical College and Hospital, RIICO Industrial Area, Sitapura, Jaipur 302022, India.
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Puri P, Kotwal N. An Approach to the Management of Diabetes Mellitus in Cirrhosis: A Primer for the Hepatologist. J Clin Exp Hepatol 2022; 12:560-574. [PMID: 35535116 PMCID: PMC9077234 DOI: 10.1016/j.jceh.2021.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 09/07/2021] [Indexed: 12/12/2022] Open
Abstract
The management of diabetes in cirrhosis and liver transplantation can be challenging. There is difficulty in diagnosis and monitoring of diabetes as fasting blood sugar values are low and glycosylated hemoglobin may not be a reliable marker. The challenges in the management of diabetes in cirrhosis include the likelihood of cognitive impairment, risk of hypoglycemia, altered drug metabolism, frequent renal dysfunction, risk of lactic acidosis, and associated malnutrition and sarcopenia. Moreover, calorie restriction and an attempt to lose weight in obese diabetics may be associated with a worsening of sarcopenia. Many commonly used antidiabetic drugs may be unsafe or be associated with a high risk of hypoglycemia in cirrhotics. Post-transplant diabetes is common and may be contributed by immunosuppressive medication. There is inadequate clinical data on the use of antidiabetic drugs in cirrhosis, and the management of diabetes in cirrhosis is hampered by the lack of guidelines focusing on this issue. The current review aims at addressing the practical management of diabetes by a hepatologist.
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Key Words
- ADA, American Diabetes Association
- AGI, Alfa Glucosidase inhibitors
- BMI, Body mass index
- CLD, Chronic liver disease
- CYP-450, Cytochrome P-450
- Dipeptidyl-peptidase 4, DPP-4
- GLP-1, Glucagon-like peptide-1
- HCC, Hepatocellular carcinoma
- HCV, Hepatitis C virus
- HbA1c, Hemoglobin A1c
- IGF, Insulin-like growth factor
- MALA, Metformin-associated lactic acidosis
- NASH, Nonalcoholic steatohepatitis
- NPL, Neutral protamine lispro
- OGTT, Oral glucose tolerance test
- SMBG, Self-monitoring of blood glucose
- Sodium-glucose cotransporter 2, SGLT2
- VEGF, Vascular endothelial growth factor
- antidiabetic agents
- antihyperglycemic drugs
- chronic liver disease
- cirrhosis
- diabetes mellitus
- eGFR, estimated glomerular filtration rates
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Affiliation(s)
- Pankaj Puri
- Fortis Escorts Liver and Digestive Diseases Institute, New Delhi, 110025, India,Address for correspondence: Dr Pankaj Puri, DNB, DM (Gastroenterology), FRCP (Edinburgh), FRCP (London) Director, Gastroenterology and Hepatology Fortis Escorts Hospital Okhla Road, New Delhi, 110025, India.
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Limdi JK. Editorial commentary on the Indian Journal of Gastroenterology-May-June 2022. Indian J Gastroenterol 2022; 41:213-217. [PMID: 35704177 PMCID: PMC9198610 DOI: 10.1007/s12664-022-01266-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Jimmy K Limdi
- grid.451052.70000 0004 0581 2008Section of Inflammatory Bowel Diseases, Division of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Manchester, UK ,grid.5379.80000000121662407University of Manchester, Manchester, UK ,grid.25627.340000 0001 0790 5329Manchester Metropolitan University, Manchester, UK
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Yang H, Zhang MZH, Sun HW, Chai YT, Li X, Jiang Q, Hou J. A Novel Microcrystalline BAY-876 Formulation Achieves Long-Acting Antitumor Activity Against Aerobic Glycolysis and Proliferation of Hepatocellular Carcinoma. Front Oncol 2021; 11:783194. [PMID: 34869036 PMCID: PMC8636331 DOI: 10.3389/fonc.2021.783194] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/15/2021] [Indexed: 12/17/2022] Open
Abstract
BAY-876 is an effective antagonist of the Glucose transporter type 1 (GLUT1) receptor, a mediator of aerobic glycolysis, a biological process considered a hallmark of hepatocellular carcinoma (HCC) together with cell proliferation, drug-resistance, and metastasis. However, the clinical application of BAY-876 has faced many challenges. In the presence study, we describe the formulation of a novel microcrystalline BAY-876 formulation. A series of HCC tumor models were established to determine not only the sustained release of microcrystalline BAY-876, but also its long-acting antitumor activity. The clinical role of BAY-876 was confirmed by the increased expression of GLUT1, which was associated with the worse prognosis among advanced HCC patients. A single dose of injection of microcrystalline BAY-876 directly in the HCC tissue achieved sustained localized levels of Bay-876. Moreover, the single injection of microcrystalline BAY-876 in HCC tissues not only inhibited glucose uptake and prolonged proliferation of HCC cells, but also inhibited the expression of epithelial-mesenchymal transition (EMT)-related factors. Thus, the microcrystalline BAY-876 described in this study can directly achieve promising localized effects, given its limited diffusion to other tissues, thereby reducing the occurrence of potential side effects, and providing an additional option for advanced HCC treatment.
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Affiliation(s)
- Hua Yang
- Department of Medical Oncology, Affiliated Hospital of Hebei University, Hebei Key Laboratory of Cancer Radiotherapy and Chemotherapy, Baoding, China
| | - Mu-Zi-He Zhang
- Department of Pharmacy, Medical Security Center of PLA General Hospital, Beijing, China
| | - Hui-Wei Sun
- Department of Infectious Disease, Institute of Infectious Disease, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yan-Tao Chai
- Department of Infectious Disease, Institute of Infectious Disease, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiaojuan Li
- Department of Infectious Disease, Institute of Infectious Disease, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qiyu Jiang
- Department of Infectious Disease, Institute of Infectious Disease, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jun Hou
- Department of Infectious Disease, Institute of Infectious Disease, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
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Larrosa-Haro A, Caro-Sabido EA. Secondary Malnutrition and Nutritional Intervention in Cholestatic Liver Diseases in Infants. Front Nutr 2021; 8:716613. [PMID: 34869514 PMCID: PMC8636107 DOI: 10.3389/fnut.2021.716613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/22/2021] [Indexed: 12/12/2022] Open
Abstract
We aimed to conduct an updated review on the pathophysiology, diagnosis, and nutritional intervention of CCLD and secondary malnutrition in infants. Protein-energy malnutrition, impaired linear growth, fat-soluble vitamin deficiencies, and hepatic osteodystrophy can occur in up to 80% of cases. The proposed pathophysiological mechanisms include insufficient energy intake, lipid- and fat-soluble vitamin malabsorption, increased energy expenditure, altered intermediate metabolism, hormonal dysregulation, and systemic inflammation. The current approach to diagnosis is the identification of the deviation of growth parameters, body composition, and serum concentration of micronutrients, which determines the type and magnitude of malnutrition. Currently, liver transplantation is the best therapeutic alternative for the reversal of nutritional impairment. Early and effective portoenteroanatomosis can extend survival in patients with biliary atresia. Medical and dietary interventions in some storage and metabolic diseases can improve liver damage and thus the nutritional status. A proportion of patients with biliary atresia have fat-soluble vitamin deficiencies despite receiving these vitamins in a water-soluble form. With aggressive enteral nutrition, it may be possible to increase fat stores and preserve muscle mass and growth. The nutritional issues identified in the pre- and post-transplantation stages include muscle mass loss, bone demineralization, growth retardation, and obesity, which seems to correspond to the natural history of CCLD. Due to the implications for the growth and development of infants with CCLD with this complex malnutrition syndrome, innovative projects are required, such as the generation of prediction and risk models, biomarkers of growth and body composition, and effective strategies for nutritional prevention and intervention.
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Affiliation(s)
- Alfredo Larrosa-Haro
- Instituto de Nutrición Humana, Departamento de Clínicas de la Reproducción Humana, Crecimiento y Desarrollo Infantil, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
| | - Erika A. Caro-Sabido
- Departamento de Salud Pública, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
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Ayorinde T, Panayotova G, Sharma A, Lunsford KE. Clinical and biomarker assessment of frailty in liver transplantation. Curr Opin Organ Transplant 2021; 26:488-497. [PMID: 34343156 PMCID: PMC8446327 DOI: 10.1097/mot.0000000000000911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Liver cirrhosis results in progressive decline, or frailty, which leads to poor outcomes and decreased survival. Multiple biomarkers and clinical assessment tools for quantifying frailty in liver transplant candidates exist, but a universal scoring protocol is lacking. Criteria vary between studies and correlation with patient outcome is not always clear. This review aims to summarize the pertinent biomarkers and assessment tools of frailty in cirrhosis. RECENT FINDINGS As cirrhosis progresses, the resultant 'frailty' is an inseparable independent predictor of pre and posttransplant mortality. Pro-inflammatory, neuroendocrine, and adipokine factors are dysregulated - leading to paradoxical anorexia and downregulation of orexigenic signals. The resulting catabolic utilization of amino and fatty acids leads to progressive malnutrition and sarcopenia. Both functional and imaging criteria define sarcopenia in cirrhotic patients, and degree of debilitation correlates with mortality. Liver-disease-specific frailty biomarkers and scoring tools are optimal to assess physical dysfunction in cirrhotics to promote early diagnosis and intervention. SUMMARY Liver cirrhosis and resulting frailty are progressive and portend a poor patient prognosis. A comprehensive, validated algorithm for detecting and quantifying frailty specific to liver disease would allow for standardization and facile application in the clinical setting. Early diagnosis is key for timely intervention and improved patient outcomes.
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Affiliation(s)
- Tumininu Ayorinde
- Division of Transplant and HPB Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Guergana Panayotova
- Division of Transplant and HPB Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Aanchal Sharma
- Division of Transplant and HPB Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Keri E. Lunsford
- Division of Transplant and HPB Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
- Center for Immunity and Inflammation, Institute for Infectious and Inflammatory Diseases, Rutgers New Jersey Medical School, Newark, NJ
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Anand A, Saraya A. Assessment of Sarcopenia in Chronic Liver Disease: Indian Perspective. Clin Liver Dis (Hoboken) 2021; 18:164-167. [PMID: 34691405 PMCID: PMC8518340 DOI: 10.1002/cld.1142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/12/2021] [Accepted: 05/18/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Abhinav Anand
- Department of Gastroenterology and Human Nutrition UnitAll India Institute of Medical SciencesNew DelhiIndia
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition UnitAll India Institute of Medical SciencesNew DelhiIndia
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Sharma S, Yegurla J, Singh N, Gunjan D, Saraya A. Duration of Fasting During Acute Variceal Bleeding in Chronic Liver Disease: Perceptions and Practices of Gastroenterologists. J Clin Exp Hepatol 2021; 11:753-755. [PMID: 34866854 PMCID: PMC8617526 DOI: 10.1016/j.jceh.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/01/2021] [Indexed: 12/12/2022] Open
Affiliation(s)
| | | | | | | | - Anoop Saraya
- Address for correspondence: Anoop Saraya, Professor and Head of Department, Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India.
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