1
|
Li XQ, Liang Y, Huang CF, Li SN, Cheng L, You C, Liu YX, Wang T. Advancements in nutritional diagnosis and support strategies during the perioperative period for patients with liver cancer. World J Gastrointest Surg 2024; 16:2409-2425. [PMID: 39220056 PMCID: PMC11362955 DOI: 10.4240/wjgs.v16.i8.2409] [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: 03/08/2024] [Revised: 05/27/2024] [Accepted: 06/24/2024] [Indexed: 08/16/2024] Open
Abstract
Liver cancer represents a grave hepatic condition and constitutes a significant global health concern. Surgical resection remains the principal therapeutic modality for liver cancer. Nevertheless, perioperative malnutrition exerts a notable impact on patients with liver cancer, emerging as an independent risk factor for disease mortality and adverse outcomes. Hence, precise nutritional diagnosis and timely nutritional support hold the potential to enhance therapeutic efficacy and quality of life for liver cancer patients. This study represents a meticulous foray into the literature, extracting data from PubMed, Web of Science, and EMBASE databases, with a focus on the past 5 years. It scrutinizes the impact of malnutrition on patients undergoing liver cancer surgery, the etiological underpinnings of malnutrition within this patient cohort, the critical assessment of perioperative nutritional status, and the strategic approaches to nutritional support. Utilizing rigorous inclusion and exclusion criteria, the amassed scholarly works are meticulously synthesized, methodically organized, and categorically elaborated upon. Ultimately, the authors propose the incorporation of a multidisciplinary nutrition management team during the perioperative period, comprising nutritionists, pharmacists, physicians, nurses, psychologists, and rehabilitation therapists, among other specialized professionals. Together, they collaborate to devise and implement personalized nutritional support plans, monitor patients' nutritional status, and make necessary adjustments as required. Through comprehensive management and intervention, improvements in the nutritional status of liver cancer patients can be achieved, thereby enhancing surgical success rates and facilitating postoperative recovery. It is believed that this manuscript will offer valuable insights to advance the nutritional management during the perioperative phase of liver cancer, aiding in ameliorating patients' nutritional status and treatment outcomes.
Collapse
Affiliation(s)
- Xiao-Qin Li
- Department of Hepatobiliary Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Yun Liang
- Department of Paediatric Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Chen-Feng Huang
- Department of Cardiovascular Surgery, The First Affiliated Hospital, Jinan University, Guangzhou 510632, Guangdong Province, China
| | - Sui-Ning Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital, Jinan University, Guangzhou 510632, Guangdong Province, China
| | - Lei Cheng
- Department of Hepatobiliary Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Chuan You
- Department of Hepatobiliary Surgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Yao-Xia Liu
- Department of Geriatric Endocrinology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, Sichuan Province, China
| | - Tao Wang
- Department of Pediatric Cardiology, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, Sichuan Province, China
| |
Collapse
|
2
|
Reincke M, Seufert J, Laubner K, Meyer-Steenbuck M, Dammer A, Sturm L, Thimme R, Bettinger D, Schultheiss M. Reduced bone mineral density is associated to post-TIPS survival of female patients with decompensated cirrhosis. Dig Liver Dis 2024:S1590-8658(24)00710-2. [PMID: 38679509 DOI: 10.1016/j.dld.2024.04.009] [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: 01/10/2024] [Revised: 04/10/2024] [Accepted: 04/10/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Malnutrition is common in patients with cirrhosis, eventually leading to sarcopenia and loss of bone mass. AIMS The aims of this study was the assessment of body composition (BC) and bone mineral density (BMD) in patients with decompensated cirrhosis and the prognostic impact on survival after transjugular intrahepatic portosystemic shunt (TIPS) implantation. METHODS BMD and BC of 107 patients with cirrhosis undergoing TIPS implantation were prospectively analyzed by dual-energy X-ray absorptiometry. The prevalence and predisposing risk factors for reduced BMD and sarcopenia were assessed. Impact on 12-month survival after TIPS implantation was evaluated. RESULTS Sarcopenia was diagnosed in 48.6 % of the patients with a predominance of male patients (58.7% vs. 25.0 %, p = 0.001). 67.2 % had reduced BMD. Low BMI was independently associated with sarcopenia (OR 0.751 (95 % CI: 0.662;0.852), p < 0.001) and reduced BMD (OR 0.851 (0.773;0.937), p = 0.001). Patients with reduced BMD, but not sarcopenia, had impaired 12-month survival after TIPS-implantation (61.2% vs. 82.9 %, p = 0.030). Subgroup analysis showed that this was especially valid for female patients. CONCLUSIONS Sarcopenia and reduced BMD are frequently observed in patients with decompensated cirrhosis. Reduced BMD negatively affects post-TIPS survival. Since malnutrition is a leading cause, assessment of nutritional status and specific treatment should be included in clinical practice.
Collapse
Affiliation(s)
- Marlene Reincke
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Jochen Seufert
- Department of Medicine II, Division of Endocrinology and Diabetology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Katharina Laubner
- Department of Medicine II, Division of Endocrinology and Diabetology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany
| | - Maximilian Meyer-Steenbuck
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Anna Dammer
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Lukas Sturm
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Michael Schultheiss
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany.
| |
Collapse
|
3
|
Lan T, Chen M, Tang C, Deltenre P. Recent developments in the management of ascites in cirrhosis. United European Gastroenterol J 2024; 12:261-272. [PMID: 38340308 PMCID: PMC10954428 DOI: 10.1002/ueg2.12539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/05/2023] [Indexed: 02/12/2024] Open
Abstract
In recent years, advances have been made for treating ascites in patients with cirrhosis. Recent studies have indicated that several treatments that have been used for a long time in the management of portal hypertension may have beneficial effects that were not previously identified. Long-term albumin infusion may improve survival in patients with cirrhosis and ascites while beta-blockers may reduce ascites occurrence. Transjugular intrahepatic porto-systemic shunt (TIPS) placement may also improve survival in selected patients in addition to the control with ascites. Low-flow ascites pump insertion can be another option for some patients with intractable ascites. In this review, we summarize the latest data related to the management of ascites occurring in cirrhosis. There are still unanswered questions, such as the optimal use of albumin as a long-term therapy, the place of beta-blockers, and the best timing for TIPS placement to improve the natural history of ascites, as well as the optimal stent diameter to reduce the risk of shunt-related side-effects. These issued should be addressed in future studies.
Collapse
Affiliation(s)
- Tian Lan
- Lab of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Chen
- Lab of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Chengwei Tang
- Lab of Gastroenterology and Hepatology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Pierre Deltenre
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Department of Gastroenterology and Hepatology, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
- Department of Gastroenterology and Hepatology, Clinique St Luc, Bouge, Belgium
| |
Collapse
|
4
|
de Felice I, Ridola L, Riggio O, Faccioli J, Nardelli S, Gioia S. Transjugular Intrahepatic Portosystemic Shunt Placement: Effects on Nutritional Status in Cirrhotic Patients. J Clin Med 2023; 12:7029. [PMID: 38002642 PMCID: PMC10672441 DOI: 10.3390/jcm12227029] [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: 09/27/2023] [Revised: 10/27/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Malnutrition is a tangible complication of cirrhosis with portal hypertension with a prevalence of up to 50%. In particular, sarcopenia and myosteatosis, defined as the alteration in muscle quantity and quality, have a negative impact on the main complications of liver disease and are associated with higher mortality in patients with cirrhosis. Recently, alterations in adipose tissue have also been described in cirrhotic patients and they seem to influence the course of liver disease. Several pieces of evidence indicate that a transjugular intrahepatic portosystemic shunt (TIPS), placed for the treatment of refractory portal hypertension, can lead to a modification of body composition consisting in the improvement of the skeletal muscle index, myosteatosis, and an increase in subcutaneous fat. These modifications of the nutritional status, even more pronounced in sarcopenic patients before TIPS, have been associated with an amelioration of cognitive impairment after TIPS as well as with an increase in the survival rate. The aim of this paper is to provide an overview of the effects of TIPS placement on nutritional status in cirrhosis focusing on its pathophysiological mechanisms and its relationship with liver-related outcomes.
Collapse
Affiliation(s)
| | | | | | | | | | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (I.d.F.); (L.R.); (O.R.); (J.F.); (S.N.)
| |
Collapse
|
5
|
Thevenot T, Desmarets M, Weil D, Di Martino V. Diameter of the shunt: the missing link in the appraisal of pTIPS in patients with cirrhosis with previous hepatic encephalopathy. Gut 2023; 72:2189-2190. [PMID: 36328411 DOI: 10.1136/gutjnl-2022-328761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Thierry Thevenot
- Service d'Hépatologie et de Soins Intensifs Digestifs, Hôpital Jean Minjoz, Besançon, France
| | - Maxime Desmarets
- uMETh, Centre d'investigation Clinique 1431, Hôpital Jean Minjoz, Besançon, France
- UMR1098 Right, Inserm, Établissement Français du Sang, Université Bourgogne-Franche-Comté, Besançon, France
| | - Delphine Weil
- Service d'Hépatologie et de Soins Intensifs Digestifs, Hôpital Jean Minjoz, Besançon, France
| | - Vincent Di Martino
- Service d'Hépatologie et de Soins Intensifs Digestifs, Hôpital Jean Minjoz, Besançon, France
| |
Collapse
|
6
|
March C, Thormann M, Geipel S, Sowa JP, Barajas Ordonez F, Pech M, Omari J, Lemmer P. Increase of radiologically determined muscle area in patients with liver cirrhosis after transjugular intrahepatic portosystemic shunt. Sci Rep 2023; 13:17092. [PMID: 37816875 PMCID: PMC10564886 DOI: 10.1038/s41598-023-43938-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/30/2023] [Indexed: 10/12/2023] Open
Abstract
Sarcopenia is common in patients with liver cirrhosis and related to higher mortality. Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is a feasible method for reducing cirrhosis-related portal hypertension, but also possible improvement of the patient`s muscle status. We aimed to analyze changes in muscle quantity and prevalence of sarcopenia after TIPS. We retrospectively surveyed the muscle status in 52 patients (mean age 54.2 years) before and after TIPS by evaluating skeletal (SMI) and psoas muscle indices (PMI) in CT and MR images. Model for End-Stage Liver Disease (MELD), Freiburg index of post-TIPS survival (FIPS), and their underlying laboratory parameters (e.g., Albumin) were analyzed. Prevalence of sarcopenia was 84.6%. After a median follow-up of 16.5 months after TIPS, SMI (0.020) and PMI (p < 0.001) increased, and sarcopenia decreased by 14.8% (0.109). MELD and PMI after TIPS were negatively correlated (r = - 0.536, p < 0.001). Albumin levels increased in patients with increased SMI after TIPS (p = 0.022). Confirming the positive impact of TIPS implantation on muscle indices in patients with liver cirrhosis, we found indications for improved survival and possible indications for altered metabolism with increased albumin levels in patients with increased muscle quantity.
Collapse
Affiliation(s)
- Christine March
- Department of Radiology and Nuclear Medicine, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39112, Magdeburg, Germany.
- Department of Radiology and Nuclear Medicine, University of Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
| | - Maximilian Thormann
- Department of Radiology and Nuclear Medicine, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39112, Magdeburg, Germany
| | - Sarah Geipel
- Department of Radiology and Nuclear Medicine, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39112, Magdeburg, Germany
| | - Jan-Peter Sowa
- Department of Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Ruhr University, Bochum, In der Schornau 23-25, 44892, Bochum, Germany
| | - Felix Barajas Ordonez
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Maciej Pech
- Department of Radiology and Nuclear Medicine, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39112, Magdeburg, Germany
| | - Jazan Omari
- Department of Radiology and Nuclear Medicine, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39112, Magdeburg, Germany
| | - Peter Lemmer
- Department of Gastroenterology, Hepatology, and Infectious Diseases, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39112, Magdeburg, Germany
| |
Collapse
|
7
|
Espinosa-Flores AJ, Guzman-Ortiz E, Melendez-Mier G, Ternovoy SK, Bueno-Hernandez N, Roldan-Valadez E. A scoping review of the methods used in patients with liver cirrhosis to assess body composition and their nutritional findings. Eur J Clin Nutr 2023; 77:845-854. [PMID: 37095222 DOI: 10.1038/s41430-023-01287-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/07/2023] [Accepted: 04/13/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND AND OBJECTIVES Body composition (BC) assessment in cirrhosis has a wide variety of methods with no consensus on the best tools for each body component in patients with Liver Cirrhosis (LC). We aimed to conduct a systematic scoping review of the most frequent body composition analysis methods and nutritional findings published in liver cirrhosis patients. METHODS We searched for articles in PubMed, Scopus, and ISI Web of Science databases. Keywords selected the BC methods and parameters in LC. RESULTS Eleven methods were found. The most frequently used were computed tomography (CT) 47.5%, Bioimpedance Analysis 35%, DXA 32.5%, and anthropometry 32.5%. Up to 15 BC parameters were reported from each method. CONCLUSIONS The vast heterogeneity in the results found during the qualitative analysis and imaging methods must reach a consensus to achieve a better clinical practice and improve nutritional treatment, as the physiopathology in LC compromises the nutritional status directly.
Collapse
Affiliation(s)
- Aranza-Jhosadara Espinosa-Flores
- Laboratory for Proteomics and Metabolomics, Research Division, Hospital General de Mexico "Dr Eduardo Liceaga,", 06720, Mexico City, Mexico
| | - Elizabeth Guzman-Ortiz
- Department of Nursing and Obstetrics, Universidad de Guanajuato, 36000, Celaya City, Mexico
| | | | - Sergey K Ternovoy
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, 127005, Moscow, Russia
| | - Nallely Bueno-Hernandez
- Laboratory for Proteomics and Metabolomics, Research Division, Hospital General de Mexico "Dr Eduardo Liceaga,", 06720, Mexico City, Mexico.
| | - Ernesto Roldan-Valadez
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia.
- Directorate of Research, Hospital General de Mexico "Dr Eduardo Liceaga", 06720, Mexico City, Mexico.
| |
Collapse
|
8
|
Hey P, Chapman B, Wong D, Gow P, Testro A, Terbah R, Sinclair M. Transjugular intrahepatic portosystemic shunt insertion improves muscle mass but not muscle function or frailty measures. Eur J Gastroenterol Hepatol 2023; 35:997-1003. [PMID: 37395688 DOI: 10.1097/meg.0000000000002592] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
INTRODUCTION Sarcopenia in cirrhosis is associated with poor outcomes. While transjugular intrahepatic portosystemic shunt (TIPS) insertion improves radiological measures of muscle mass, its impact on muscle function, performance and frailty has not been evaluated. METHODS Patients with cirrhosis referred for TIPS were prospectively recruited and followed for 6 months. L3 CT scans were used to calculate skeletal muscle and adipose tissue parameters. Handgrip strength, Liver Frailty Index and short physical performance battery were serially monitored. Dietary intake, insulin resistance, insulin-like growth factor (IGF)-1, and immune function using QuantiFERON Monitor (QFM) were measured. RESULTS Twelve patients completed the study with a mean age of 58 ± 9 years and model for end-stage liver disease score of 16 ± 5. At 6 months post-TIPS, skeletal muscle area increased from 139.33 cm 2 ± 22.72 to 154.64 ± 27.42 ( P = 0.012). Significant increases were observed in the subcutaneous fat area ( P = 0.0076) and intermuscular adipose tissue ( P = 0.041), but not muscle attenuation or visceral fat. Despite marked changes in muscle mass, no improvements were observed in handgrip strength, frailty, or physical performance. At 6 months post-TIPS, IGF-1 ( P = 0.0076) and QFM ( P = 0.006) increased compared to baseline. Nutritional intake, hepatic encephalopathy measures, insulin resistance and liver biochemistry were not significantly impacted. CONCLUSION Muscle mass increased following TIPS insertion as did IGF-1, a known driver of muscle anabolism. The lack of improvement in muscle function was unexpected and may relate to impairment in muscle quality and the effects of hyperammonaemia on muscle contractile function. Improvements in QFM, a marker of immune function, may suggest a reduction in infection susceptibility in this at-risk population and requires further evaluation.
Collapse
Affiliation(s)
- Penelope Hey
- Department of Gastroenterology, Austin Health, Heidelberg
- Department of Medicine, The University of Melbourne, Parkville
| | - Brooke Chapman
- Department of Gastroenterology, Austin Health, Heidelberg
- Department of Medicine, The University of Melbourne, Parkville
- Department of Nutrition and Dietetics, Austin Health, Heidelberg, Victoria, Australia
| | - Darren Wong
- Department of Gastroenterology, Austin Health, Heidelberg
- Department of Medicine, The University of Melbourne, Parkville
| | - Paul Gow
- Department of Gastroenterology, Austin Health, Heidelberg
- Department of Medicine, The University of Melbourne, Parkville
| | - Adam Testro
- Department of Gastroenterology, Austin Health, Heidelberg
- Department of Medicine, The University of Melbourne, Parkville
| | - Ryma Terbah
- Department of Gastroenterology, Austin Health, Heidelberg
- Department of Medicine, The University of Melbourne, Parkville
| | - Marie Sinclair
- Department of Gastroenterology, Austin Health, Heidelberg
- Department of Medicine, The University of Melbourne, Parkville
| |
Collapse
|
9
|
Chen Q, Bao L, Yue Z, Wang L, Fan Z, Liu F. Adverse events after the transjugular intrahepatic portal shunt are linked to serum metabolomic changes following the procedure. Front Mol Biosci 2023; 10:1168782. [PMID: 37255539 PMCID: PMC10225654 DOI: 10.3389/fmolb.2023.1168782] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/03/2023] [Indexed: 06/01/2023] Open
Abstract
Background and Objective: Transjugular intrahepatic portal shunt (TIPS) insertion could promote weight gain and muscle and fat mass increase in patients with cirrhosis. However, few studies have focused on metabolic changes after TIPS. This study aims to explore metabolic changes after TIPS and potential biomarkers of adverse events. Methods: Peripheral and portal serum samples were collected before and after TIPS insertion. Untargeted metabolomics was performed using ultra-high-performance liquid chromatography-mass spectrometry. Spearman's correlation analysis was used to determine the relationship between metabolites and clinical parameters. Metabolite set enrichment analysis was performed to explore enriched pathways. The predictive value of the metabolites was calculated by receiver operating characteristic curve (ROC) analysis. Results: Metabolites in the peripheral and portal serum significantly changed early after TIPS. Some lipid metabolites were significantly correlated with liver function parameters. Both elevated and depleted metabolites were mainly enriched in amino acid metabolism. Nine and 12 portal metabolites have moderate predictive value in post-TIPS liver function decline and hepatic encephalopathy (HE), separately (area under curve >0.7). Conclusion: Metabolites in the peripheral and portal veins significantly changed after TIPS. Some metabolic changes might be ascribed to liver function decline early after TIPS. Nine and 12 portal metabolites might be potential biomarkers in prediction of liver function decline and HE, separately.
Collapse
Affiliation(s)
- Quan Chen
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Li Bao
- Department of Pharmacy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Zhendong Yue
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Lei Wang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Zhenhua Fan
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Fuquan Liu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
10
|
Gazda J, Di Cola S, Lapenna L, Khan S, Merli M. The Impact of Transjugular Intrahepatic Portosystemic Shunt on Nutrition in Liver Cirrhosis Patients: A Systematic Review. Nutrients 2023; 15:nu15071617. [PMID: 37049459 PMCID: PMC10096634 DOI: 10.3390/nu15071617] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/14/2023] [Accepted: 03/25/2023] [Indexed: 03/29/2023] Open
Abstract
Background and Aims: Liver cirrhosis leads to clinically significant portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) has been shown to effectively reduce the degree of portal hypertension and treat its complications. However, poor nutritional status has been shown to be associated with hepatic encephalopathy, acute on chronic liver failure, and mortality following TIPS placement. The purpose of this systematic review is to create another perspective and evaluate the effect of TIPS placement on the nutritional status of patients with liver cirrhosis. Methods: A comprehensive search of four major electronic databases was conducted to identify studies that assessed the nutritional status of cirrhotic patients before and after TIPS placement. The risk of bias was evaluated using ROBINS-I guidelines. Results: Fifteen studies were analyzed in this review. The results indicate that among the 11 studies that evaluated changes in ascites-free weight and body mass index or body cell mass, 10 reported an improvement in one or more measures. Furthermore, all seven studies that evaluated changes in muscle mass demonstrated an increase in muscle mass. Among the four studies that evaluated subcutaneous fat tissue, three showed a significant expansion, while two out of three studies evaluating visceral fat tissue reported a significant reduction. Conclusions: The results of this systematic review suggest that TIPS placement is associated with improvement in the nutritional status of cirrhotic patients, indicated by an increase in ascites-free weight, body mass index, and muscle mass. Additionally, TIPS placement leads to a shift in the distribution of fat mass, with a preference for subcutaneous over visceral adipose tissue. Notably, sarcopenic patients seem to benefit the most from TIPS placement in terms of nutritional status.
Collapse
Affiliation(s)
- Jakub Gazda
- 2nd Department of Internal Medicine, Pavol Jozef Safarik University and Louis Pasteur University Hospital, 040 12 Kosice, Slovakia
| | - Simone Di Cola
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Lucia Lapenna
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Saniya Khan
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
- Correspondence: ; Tel.: +39-06-49972001
| |
Collapse
|
11
|
Wu CH, Ho MC, Kao JH, Ho CM, Su TH, Hsu SJ, Huang HY, Lin CY, Liang PC. Effects of transjugular intrahepatic portosystemic shunt on abdominal muscle mass in patients with decompensated cirrhosis. J Formos Med Assoc 2023:S0929-6646(23)00061-X. [PMID: 36868900 DOI: 10.1016/j.jfma.2023.02.007] [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: 10/19/2022] [Revised: 01/31/2023] [Accepted: 02/19/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Sarcopenia is a common finding in patients with decompensated cirrhosis without effective therapy. We aimed to examine whether a transjugular portosystemic shunt (TIPS) could improve the abdominal muscle mass assessed by cross-sectional images in patients with decompensated cirrhosis and to investigate the association of imaging-defined sarcopenia with the prognosis of such patients. METHODS In this retrospective observational study, we enrolled 25 Decompensated cirrhosis patients aged >20 who received TIPS for the control of variceal bleeding or refractory ascites between April 2008 and April 2021. All of them underwent preoperative computed tomography or magnetic resonance imaging, which was used to determine psoas muscle (PM) and paraspinal muscle (PS) indices at the third lumbar vertebra. First, we compared baseline muscle mass with muscle mass at 6 and 12 months after TIPS placement and analyzed PM- and PS-defined sarcopenia to predict mortality. RESULTS Among 25 patients, 20 (80.0%) and 12 (48.0%) had PM- and PS-defined sarcopenia, respectively, at baseline. In total, 16 and 8 patients were followed up for 6 and 12 months, respectively. All imaging-based muscle measurements performed 12 months after TIPS placement were significantly greater than the baseline measurements (all p < 0.05). Unlike patients with PS-defined sarcopenia (p = 0.529), patients with PM-defined sarcopenia had poorer survival than did patients without (p = 0.036). CONCLUSIONS PM mass in patients with decompensated cirrhosis may increase by 6 or 12 months after TIPS placement and imply a better prognosis. Patients with preoperative PM-defined sarcopenia may suggest poorer survival.
Collapse
Affiliation(s)
- Chih-Horng Wu
- Department of Medical Imaging and Radiology, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming-Chih Ho
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan; Center for Functional and Interventional Image, National Taiwan University, Taipei, Taiwan; Department of Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Jia-Horng Kao
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Cheng-Maw Ho
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tung-Hung Su
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shih-Jer Hsu
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsiang-Yun Huang
- Department of Medical Imaging and Radiology, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chun-Yu Lin
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Po-Chin Liang
- Department of Medical Imaging and Radiology, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Medical Imaging, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.
| |
Collapse
|
12
|
Deltenre P, Zanetto A, Saltini D, Moreno C, Schepis F. The role of transjugular intrahepatic portosystemic shunt in patients with cirrhosis and ascites: Recent evolution and open questions. Hepatology 2023; 77:640-658. [PMID: 35665949 DOI: 10.1002/hep.32596] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/14/2022] [Accepted: 05/16/2022] [Indexed: 01/28/2023]
Abstract
In selected patients with cirrhosis and ascites, transjugular intrahepatic portosystemic shunt (TIPS) placement improves control of ascites and may reduce mortality. In this review, we summarize the current knowledge concerning the use of TIPS for the treatment of ascites in patients with cirrhosis, from pathophysiology of ascites formation to hemodynamic consequences, patient selection, and technical issues of TIPS insertion. The combination of these factors is important to guide clinical decision-making and identify the best strategy for each individual patient. There is still a need to identify the best timing for TIPS placement in the natural history of ascites (recurrent vs. refractory) as well as which type and level of renal dysfunction is acceptable when TIPS is proposed for the treatment of ascites in cirrhosis. Future studies are needed to define the optimal stent diameter according to patient characteristics and individual risk of shunt-related side effects, particularly hepatic encephalopathy and insufficient cardiac response to hemodynamic consequences of TIPS insertion.
Collapse
Affiliation(s)
- Pierre Deltenre
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology , CUB Hôpital Erasme, Université Libre de Bruxelles , Brussels , Belgium.,Department of Gastroenterology and Hepatology , CHU UCL Namur, Université Catholique de Louvain , Yvoir , Belgium.,Department of Gastroenterology and Hepatology , Clinique St Luc , Bouge , Belgium
| | - Alberto Zanetto
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy.,Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology , Padova University Hospital , Padova , Italy
| | - Dario Saltini
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology , CUB Hôpital Erasme, Université Libre de Bruxelles , Brussels , Belgium.,Laboratory of Experimental Gastroenterology , Université Libre de Bruxelles , Brussels , Belgium
| | - Filippo Schepis
- Division of Gastroenterology, Hepatic Hemodynamic Laboratory , Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia , Modena , Italy
| |
Collapse
|
13
|
Barbosa FA, Nardelli MJ, Cançado GGL, Silva CF, Osório FMF, Melo RFQ, Taranto DOL, Ferrari TCA, Couto CA, Faria LC. Sarcopenia, body composition and factors associated with variceal gastrointestinal bleeding and splenectomy in hepatosplenic schistosomiasis mansoni. Trans R Soc Trop Med Hyg 2022; 116:1145-1153. [PMID: 35748511 DOI: 10.1093/trstmh/trac052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 05/01/2022] [Accepted: 06/02/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Sarcopenia is a common complication of cirrhosis and an important predictor of morbimortality. We aimed to determine the prevalence of sarcopenia and its associated factors in hepatosplenic schistosomiasis (HSS) as well as to evaluate whether muscle mass and function are associated with variceal upper gastrointestinal bleeding (VUGIB) and previous splenectomy in subjects without other liver diseases. METHODS We conducted a cross-sectional study including adults with HSS who underwent clinical, biochemical, anthropometric, muscle strength and physical performance evaluations and were submitted to bioelectrical impedance analysis and abdominal ultrasound. Sarcopenia was diagnosed according to the 2019 European consensus criteria. RESULTS A total of 66 patients with HSS (62.1% male; mean age 48.8±8.6 y) were included. Overall, six subjects (9.1%) were diagnosed with probable sarcopenia and none had confirmed sarcopenia. Fat-free body mass index (BMI) was independently associated with VUGIB (odds ratio 0.701 [95% confidence interval 0.51 to 0.96]; p=0.025). Compared with patients who did not undergo surgery, individuals who underwent esophagogastric devascularization combined with splenectomy (EGDS) had higher serum lipid levels, fat percentage and frequency of metabolic syndrome, with lower skeletal muscle mass index and hand grip strength. CONCLUSIONS HSS mansoni seems not to cause sarcopenia. However, a lower fat-free BMI was associated with previous VUGIB and the subgroup of patients who underwent EGDS presented higher lipid levels, fat percentage and frequency of metabolic syndrome and lower muscle mass and function.
Collapse
Affiliation(s)
- Fernanda A Barbosa
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190 - Santa Efigênia, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Mateus J Nardelli
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190 - Santa Efigênia, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Guilherme G L Cançado
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190 - Santa Efigênia, Belo Horizonte, Minas Gerais, 30130-100, Brazil.,Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 110 - Santa Efigênia, Belo Horizonte, Minas Gerais, 30130-100, Brazil.,Hospital da Polícia Militar de Minas Gerais, Rua Pacífico Mascarenhas, s/n-Santa Efigênia, Belo Horizonte, Minas Gerais, 30110-013, Brazil
| | - Catherine F Silva
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190 - Santa Efigênia, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Fernanda M F Osório
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 110 - Santa Efigênia, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Rodolfo F Q Melo
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190 - Santa Efigênia, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Daniela O L Taranto
- Serviço de Diagnóstico por Imagem, Hospital das Clínicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110 - Santa Efigênia, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Teresa C A Ferrari
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190 - Santa Efigênia, Belo Horizonte, Minas Gerais, 30130-100, Brazil.,Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 110 - Santa Efigênia, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Claudia A Couto
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190 - Santa Efigênia, Belo Horizonte, Minas Gerais, 30130-100, Brazil.,Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 110 - Santa Efigênia, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Luciana C Faria
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190 - Santa Efigênia, Belo Horizonte, Minas Gerais, 30130-100, Brazil.,Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 110 - Santa Efigênia, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| |
Collapse
|
14
|
Haj Ali S, Abu Sneineh A, Hasweh R. Nutritional assessment in patients with liver cirrhosis. World J Hepatol 2022; 14:1694-1703. [PMID: 36185724 PMCID: PMC9521456 DOI: 10.4254/wjh.v14.i9.1694] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/09/2022] [Accepted: 09/09/2022] [Indexed: 02/06/2023] Open
Abstract
Malnutrition is a liver cirrhosis complication affecting more than 20%-50% of patients. Although the term can refer to either nutrient deficiency or excess, it usually relates to undernutrition in cirrhosis settings. Frailty is defined as limited physical function due to muscle weakness, whereas sarcopenia is defined as muscle mass loss and an advanced malnutrition stage. The pathogenesis of malnutrition in liver cirrhosis is multifactorial, including decreased oral intake, maldigestion/malabsorption, physical inactivity, hyperammonemia, hypermetabolism, altered macronutrient metabolism and gut microbiome dysbiosis. Patients with chronic liver disease with a Body Mass Index of < 18.5 kg/m2 and/or decompensated cirrhosis or Child-Pugh class C are at the highest risk of malnutrition. For patients at risk of malnutrition, a detailed nutritional assessment is required, typically including a history and physical examination, laboratory testing, global assessment tools and body composition testing. The latter can be done using anthropometry, cross-sectional imaging including computed tomography or magnetic resonance, bioelectrical impedance analysis and dual-energy X-ray absorptiometry. A multidisciplinary team should screen for and treat malnutrition in patients with cirrhosis. Malnutrition and sarcopenia are associated with an increased risk of complications and a poor prognosis in patients with liver cirrhosis; thus, it is critical to diagnose these conditions early and initiate the appropriate nutritional therapy. In this review, we describe the prevalence and pathogenesis of malnutrition in liver cirrhosis patients and discuss the best diagnostic approach to nutritional assessment for them.
Collapse
Affiliation(s)
- Sara Haj Ali
- Department of Internal Medicine, Faculty of Medicine, Al-Balqa Applied University, Salt 19117, Jordan
| | - Awni Abu Sneineh
- Department of Gastroenterology and Hepatology, University of Jordan, Faculty of Medicine, Amman 11942, Jordan
| | - Reem Hasweh
- Department of Internal Medicine, Faculty of Medicine, Al-Balqa Applied University, Salt 19117, Jordan
| |
Collapse
|
15
|
Gairing SJ, Müller L, Kloeckner R, Galle PR, Labenz C. Review article: post-TIPSS hepatic encephalopathy-current knowledge and future perspectives. Aliment Pharmacol Ther 2022; 55:1265-1276. [PMID: 35181894 DOI: 10.1111/apt.16825] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/23/2022] [Accepted: 02/02/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND In light of the global rise in the burden of chronic liver diseases and liver cirrhosis, the number of patients suffering from decompensation events is expected to increase. Transjugular intrahepatic portosystemic shunts (TIPSS) provide effective long-term symptom control and may prolong transplant-free survival in portal hypertension-driven recurrent ascites and variceal bleeding. New-onset or recurrent hepatic encephalopathy (HE) after TIPSS insertion (post-TIPSS HE) represents the most severe post-interventional complication. AIMS To provide insight into the epidemiology and risk factors for post-TIPSS HE and scrutinize the current state of the art in treatment and drug therapy options. METHODS We conducted a literature search on post-TIPSS HE in patients with liver cirrhosis. RESULTS Post-TIPSS HE occurs in up to 54.5% of cases and particularly early recurrent HE is associated with a dismal prognosis. In recent years, several risk factors for the development of post-TIPSS HE have been identified. These include not only parameters reflecting liver function (model for end-stage liver disease score/Child-Pugh score) as well as cognitive dysfunction caused by minimal HE but also extrahepatic factors such as sarcopenia and common medications such as proton pump inhibitors. In addition, new data on the benefit of rifaximin and of smaller stent grafts emerged and may improve the prevention of post-TIPSS HE. CONCLUSIONS Careful selection of TIPSS candidates is of utmost importance to reduce the risk of post-TIPSS HE. In this narrative review, we provide a concise overview of the current epidemiology and risk factors of the treatment options for post-TIPSS HE.
Collapse
Affiliation(s)
- Simon Johannes Gairing
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Lukas Müller
- Department of Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Roman Kloeckner
- Department of Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter R Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.,Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| |
Collapse
|
16
|
Liu J, Ma J, Yang C, Chen M, Shi Q, Zhou C, Huang S, Chen Y, Wang Y, Li T, Xiong B. Sarcopenia in Patients with Cirrhosis after Transjugular Intrahepatic Portosystemic Shunt Placement. Radiology 2022; 303:711-719. [PMID: 35289658 DOI: 10.1148/radiol.211172] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Sarcopenia is frequently found in patients with cirrhosis and is associated with liver dysfunction, cirrhosis-related complications, and poorer quality of life. Purpose To evaluate changes in skeletal muscle and fat mass at CT and to evaluate the relationship of sarcopenia to mortality in patients with cirrhosis after transjugular intrahepatic portosystemic shunt (TIPS) placement. Materials and Methods Patients who underwent TIPS between August 2016 and May 2020 were included in this retrospective study. Skeletal muscle and fat mass were evaluated at CT at the L3 vertebra at baseline and at 2 months, 5 months, and 1 year after TIPS. Sarcopenia was defined as L3 skeletal muscle index (SMI) less than 50 cm2/m2 for men and less than 39 cm2/m2 for women. The primary end point was change in skeletal muscle and fat mass, and secondary end points included survival and the predictive factors for survival. Changes in skeletal muscle and fat mass over time were analyzed by generalized estimating equations. Results A total of 224 patients (159 men [113 with and 46 without sarcopenia] and 65 women [32 with and 33 without sarcopenia]) were included. In male patients with sarcopenia, the mean L3 SMI increased from 41.8 cm2/m2 (baseline) to 49.1 cm2/m2 (at 5-month follow-up; P < .001) and 49.6 cm2/m2 (at 1-year follow-up; P < .001) after TIPS. In female patients with sarcopenia, SMI increased from 33.7 cm2/m2 (at baseline) to 40.6 cm2/m2 (at 5-month follow-up; P < .001) and 42.0 cm2/m2 (at 1-year follow-up; P < .001) after TIPS. Sarcopenia (hazard ratio, 3.0; 95% CI: 1.2, 7.8) was identified as an independent risk factor for mortality after TIPS, and the patients who converted from sarcopenic to nonsarcopenic had higher cumulative survival rate than those who did not (96.4% vs 82.1%; log-rank P = .04). Conclusion In patients with sarcopenia, both skeletal muscle and fat mass increased after transjugular intrahepatic portosystemic shunt placement. The reversal of sarcopenia could reduce the risk of death. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Lee in this issue.
Collapse
Affiliation(s)
- Jiacheng Liu
- From the Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, 1277, Wuhan 430022, China; and Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jinqiang Ma
- From the Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, 1277, Wuhan 430022, China; and Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chongtu Yang
- From the Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, 1277, Wuhan 430022, China; and Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Manman Chen
- From the Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, 1277, Wuhan 430022, China; and Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Qin Shi
- From the Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, 1277, Wuhan 430022, China; and Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chen Zhou
- From the Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, 1277, Wuhan 430022, China; and Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Songjiang Huang
- From the Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, 1277, Wuhan 430022, China; and Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yang Chen
- From the Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, 1277, Wuhan 430022, China; and Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yingliang Wang
- From the Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, 1277, Wuhan 430022, China; and Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Tongqiang Li
- From the Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, 1277, Wuhan 430022, China; and Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Bin Xiong
- From the Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, 1277, Wuhan 430022, China; and Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| |
Collapse
|
17
|
Fox R, Stenning K, Slee A, Macnaughtan J, Davies N. Sarcopenia in liver cirrhosis: Prevalence, pathophysiology and therapeutic strategies. Anal Biochem 2022; 647:114581. [DOI: 10.1016/j.ab.2022.114581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 01/31/2022] [Indexed: 11/01/2022]
|
18
|
Di Cola S, Nardelli S, Ridola L, Gioia S, Riggio O, Merli M. Ammonia and the Muscle: An Emerging Point of View on Hepatic Encephalopathy. J Clin Med 2022; 11:jcm11030611. [PMID: 35160063 PMCID: PMC8836353 DOI: 10.3390/jcm11030611] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 02/06/2023] Open
Abstract
In the last years the link between the presence of muscular alterations and hepatic encephalopathy (HE), both minimal and overt, has been deeply studied. The pathophysiological background supporting the relationship between muscle depletion, and HE is characterized by an imbalance between the capacity of muscle in ammonia metabolism and trafficking and the inability of the liver in removing ammonia through urea synthesis due to liver failure and/or the presence of porto-systemic shunts. This review will focus on the clinical burden, the physio pathological mechanisms understanding the liver muscle axis and principles of management of muscular alterations in cirrhosis.
Collapse
|
19
|
Abstract
BACKGROUND the Practical Guideline is based on the current scientific ESPEN guide on Clinical Nutrition in Liver Disease. METHODS it has been shortened and transformed into flow charts for easier use in clinical practice. The guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with chronic liver disease. RESULTS a total of 103 statements and recommendations are presented with short commentaries for the nutritional and metabolic management of patients with (i) acute liver failure, (ii) alcoholic steatohepatitis, (iii) non-alcoholic fatty liver disease, (iv) liver cirrhosis, and (v) liver surgery/transplantation. Disease-related recommendations are preceded by general recommendations on the diagnosis of nutritional status in liver patients and on liver complications associated with medical nutrition. CONCLUSION this Practical Guideline gives guidance to health care providers involved in the management of liver disease on how to offer optimal nutritional care.
Collapse
|
20
|
Nutritional therapy to cirrhotic patients on transplantation waiting lists. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2021.100060] [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: 11/18/2022] Open
|
21
|
Saab S, Zhao M, Asokan I, Yum JJ, Lee EW. History of Hepatic Encephalopathy Is Not a Contraindication to Transjugular Intrahepatic Portosystemic Shunt Placement for Refractory Ascites. Clin Transl Gastroenterol 2021; 12:e00378. [PMID: 34333500 PMCID: PMC8323801 DOI: 10.14309/ctg.0000000000000378] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 05/28/2021] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The outcomes of transjugular intrahepatic portosystemic shunt (TIPS) placement in patients with hepatic encephalopathy (HE) are controversial. We studied the relationship of pre-TIPS HE in patients undergoing TIPS for refractory ascites on all-cause mortality and development of post-TIPS HE. METHODS A single-center retrospective comparison study was performed for patients undergoing TIPS for refractory ascites. Survival by history of pre-TIPS HE was demonstrated with Kaplan-Meier curves. Univariate and multivariate logistic regression analyses were performed to identify the predictors of post-TIPS clinical outcomes for patients with and without pre-TIPS HE. RESULTS We identified 202 TIPS recipients (61% male, mean ± SD; age 59.1 ± 10.2 years; mean model for end-stage liver disease score 17.3 ± 6.9). Pre-TIPS HE did not predispose patients for increased all-cause mortality, increased risk of experiencing HE within 60 days, or increased risk of hospital admission for HE within 6 months. A multivariate analysis demonstrated that total bilirubin (odds ratio [OR] 1.03; P = 0.016) and blood urea nitrogen (OR 1.15; P = 0.002) were predictors for all-cause mortality within 6 months post-TIPS. Age ≥65 years (OR 3.92; P = 0.004), creatinine (OR 2.22; P = 0.014), and Child-Pugh score (OR 1.53; P = 0.006) were predictors for HE within 60 days post-TIPS. Predictors of intensive care admission for HE within 6 months post-TIPS included age ≥65 years (OR 8.84; P = 0.018), history of any admission for HE within 6 months pre-TIPS (OR 8.42; P = 0.017), and creatinine (OR 2.22; P = 0.015). DISCUSSION If controlled, pre-TIPS HE does not adversely impact patient survival or clinical outcomes, such as development of HE within 60 days of TIPS or hospital admission for HE within 6 months. Patients may be able to undergo TIPS for refractory ascites despite a history of HE.
Collapse
Affiliation(s)
- Sammy Saab
- Division of Hepatology, Department of Medicine, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Division of Liver and Pancreas Transplantation, Department of Surgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, California, USA
| | - Matthew Zhao
- Division of Hepatology, Department of Medicine, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Ishan Asokan
- Division of Hepatology, Department of Medicine, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jung Jun Yum
- Division of Liver and Pancreas Transplantation, Department of Surgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, California, USA
| | - Edward Wolfgang Lee
- Division of Liver and Pancreas Transplantation, Department of Surgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, California, USA
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| |
Collapse
|
22
|
Traub J, Reiss L, Aliwa B, Stadlbauer V. Malnutrition in Patients with Liver Cirrhosis. Nutrients 2021; 13:540. [PMID: 33562292 PMCID: PMC7915767 DOI: 10.3390/nu13020540] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/04/2021] [Accepted: 02/04/2021] [Indexed: 12/13/2022] Open
Abstract
Liver cirrhosis is an increasing public health threat worldwide. Malnutrition is a serious complication of cirrhosis and is associated with worse outcomes. With this review, we aim to describe the prevalence of malnutrition, pathophysiological mechanisms, diagnostic tools and therapeutic targets to treat malnutrition. Malnutrition is frequently underdiagnosed and occurs-depending on the screening methods used and patient populations studied-in 5-92% of patients. Decreased energy and protein intake, inflammation, malabsorption, altered nutrient metabolism, hypermetabolism, hormonal disturbances and gut microbiome dysbiosis can contribute to malnutrition. The stepwise diagnostic approach includes a rapid prescreen, the use of a specific screening tool, such as the Royal Free Hospital Nutritional Prioritizing Tool and a nutritional assessment by dieticians. General dietary measures-especially the timing of meals-oral nutritional supplements, micronutrient supplementation and the role of amino acids are discussed. In summary malnutrition in cirrhosis is common and needs more attention by health care professionals involved in the care of patients with cirrhosis. Screening and assessment for malnutrition should be carried out regularly in cirrhotic patients, ideally by a multidisciplinary team. Further research is needed to better clarify pathogenic mechanisms such as the role of the gut-liver-axis and to develop targeted therapeutic strategies.
Collapse
Affiliation(s)
- Julia Traub
- Department of Clinical Medical Nutrition, University Hospital Graz, 8036 Graz, Austria; (J.T.); (L.R.)
| | - Lisa Reiss
- Department of Clinical Medical Nutrition, University Hospital Graz, 8036 Graz, Austria; (J.T.); (L.R.)
| | - Benard Aliwa
- Department of Gastroenterology and Hepatology, Medical University of Graz, 8036 Graz, Austria;
| | - Vanessa Stadlbauer
- Department of Gastroenterology and Hepatology, Medical University of Graz, 8036 Graz, Austria;
| |
Collapse
|
23
|
Abstract
Greater than half of patients with decompensated liver disease suffer from frailty and/or sarcopenia, which can lead to increased pre- and post-liver transplant morbidity and mortality. Although frailty and sarcopenia can impact patients with end-stage liver disease in similar ways, they are unique clinical entities with differing underlying etiologies. Early assessment and identification of frailty and sarcopenia in patients is critical to guide clinical decision-making regarding transplantation and to implement nutritional and exercise-based treatment regiments. Nonetheless, accurate diagnosis and, in particular, predicting patients that will develop frailty and/or sarcopenia remains challenging, and the success of clinical interventions is limited.
Collapse
|
24
|
Hey P, Gow P, Testro AG, Apostolov R, Chapman B, Sinclair M. Nutraceuticals for the treatment of sarcopenia in chronic liver disease. Clin Nutr ESPEN 2021; 41:13-22. [PMID: 33487256 DOI: 10.1016/j.clnesp.2020.11.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 11/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Sarcopenia, defined as loss of muscle mass, strength and function, is associated with adverse clinical outcomes in patients with cirrhosis. Despite improved understanding of the multifaceted pathogenesis, there are few established therapies to treat or prevent muscle loss in this population. This narrative review examines the available literature investigating the role of nutraceuticals for the prevention or treatment of muscle wasting in chronic liver disease. METHODS A comprehensive search or Medline and PubMED databases was conducted. Reference lists were screened to identify additional articles. RESULTS A number of nutritional supplements and vitamins target the specific metabolic derangements that contribute to sarcopenia in cirrhosis including altered amino acid metabolism, hyperammonaemia and inflammation. Branched chain amino acid (BCAA) supplementation has proposed anabolic effects through dual pathways of enhanced ammonia clearance and stimulation of muscle protein synthesis. l-carnitine also has multimodal effects on muscle and shows promise as a therapy for muscle loss through anti-inflammatory, antioxidant and ammonia lowering properties. Other nutraceuticals including l-ornithine l-aspartate, omega-3 polyunsaturated fatty acids and zinc and vitamin D supplementation, may similarly have positive effects on muscle homeostasis, however further evidence to support their use in cirrhotic populations is required. CONCLUSION Nutraceuticals offer a promising and likely safe adjunct to standard care for sarcopenia in cirrhosis. While there is most evidence to support the use of BCAA and l-carnitine supplementation, further well-designed clinical trials are needed to elucidate their efficacy as a therapy for muscle loss in this population.
Collapse
Affiliation(s)
- Penelope Hey
- Liver Transplant Unit, Austin Health, 145 Studley Rd, Heidelberg, Victoria, Australia; The University of Melbourne, Parkville, Victoria, Australia.
| | - Paul Gow
- Liver Transplant Unit, Austin Health, 145 Studley Rd, Heidelberg, Victoria, Australia; The University of Melbourne, Parkville, Victoria, Australia.
| | - Adam G Testro
- Liver Transplant Unit, Austin Health, 145 Studley Rd, Heidelberg, Victoria, Australia; The University of Melbourne, Parkville, Victoria, Australia.
| | - Ross Apostolov
- Liver Transplant Unit, Austin Health, 145 Studley Rd, Heidelberg, Victoria, Australia; The University of Melbourne, Parkville, Victoria, Australia.
| | - Brooke Chapman
- The University of Melbourne, Parkville, Victoria, Australia; Department of Nutrition and Dietetics, Austin Health, 145 Studley Rd, Heidelberg, Victoria, Australia.
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, 145 Studley Rd, Heidelberg, Victoria, Australia; The University of Melbourne, Parkville, Victoria, Australia.
| |
Collapse
|
25
|
Pang N, Zhao C, Li J, Li L, Yang X, Yang M, Wu Z, Feng D. Body mass index changes after transjugular intrahepatic portosystemic shunt in individuals with cirrhosis. Nutrition 2020; 84:111095. [PMID: 33571910 DOI: 10.1016/j.nut.2020.111095] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Liver cirrhosis is often accompanied by portal hypertension and malnutrition, two common complications that seriously affect treatment efficacy and quality of life. This study aimed to investigate the effect of transjugular intrahepatic portosystemic shunt (TIPS) on body mass index (BMI) and metabolism in individuals with cirrhotic portal hypertension, and the risk factors that affect changes of BMI. METHODS A retrospective study was performed to collect basic information before and after TIPS. This study included 77 participants. For each participant, we assayed body nutrition parameters: change of weight and BMI, routine liver and kidney function tests, and free fatty acids. In addition, we evaluated glucose and biochemical indexes. We used analysis of variance and regression analysis to investigate the effect of TIPS on BMI and metabolism in individuals with cirrhotic portal hypertension, and the risk factors that affect changes of BMI and metabolic components. RESULTS After TIPS, there was significant improvement in weight, BMI, red blood cell count, blood platelet count, hemoglobin, and Child-Pugh score in individuals with cirrhotic portal hypertension. Average weight and BMI increased after TIPS by 3.2% and 3.4%, respectively (P < 0.05). After 36 months, there were no significant differences in weight and BMI between before and after TIPS. We also observed a dose-response association of pre-TIPS blood ammonia and increased post-TIPS BMI (P = 0.05) in men. CONCLUSIONS This study suggests that individuals with cirrhosis treated with TIPS may see improvement in overall clinical and physical status, as measured by increased weight and BMI. Our data also indicate that pre-TIPS blood ammonia is positively associated with post-TIPS BMI.
Collapse
Affiliation(s)
- Ningdong Pang
- Department of Oncology and Vascular Intervention, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Chao Zhao
- Department of Oncology and Vascular Intervention, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Jinyu Li
- Department of Oncology and Vascular Intervention, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Lei Li
- Department of Oncology and Vascular Intervention, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xiaofei Yang
- Department of Oncology and Vascular Intervention, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Minling Yang
- Department of Oncology and Vascular Intervention, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Zhifeng Wu
- The Third Hospital of Shanxi Medical University, Taiyuan, China.
| | - Duiping Feng
- Department of Oncology and Vascular Intervention, First Hospital of Shanxi Medical University, Taiyuan, China.
| |
Collapse
|
26
|
Chiang RS, Parish A, Niedzwiecki D, Kappus MR, Muir AJ. Impact of Malnutrition on Outcomes in Patients Undergoing Transjugular Intrahepatic Portosystemic Shunt Insertion. Dig Dis Sci 2020; 65:3332-3340. [PMID: 31965391 DOI: 10.1007/s10620-019-06038-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/30/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND Malnutrition is common in patients with cirrhosis and is associated with poor outcomes after hepatic resection and liver transplantation. Transjugular intrahepatic portosystemic shunt (TIPS) is performed for complications of cirrhosis. AIM To assess the impact of malnutrition on TIPS outcomes. METHODS A retrospective analysis was performed using the Healthcare Cost and Utilization Project: National Inpatient Sample database for TIPS procedures from 2005 to 2014. The primary end point was in-hospital mortality. The association of specific malnutrition diagnostic codes and race-ethnicity on mortality was evaluated with survey-weighted logistic regression adjusted for age, gender, admission type, insurance payer, hospital region, comorbidities, and length of stay (LOS). RESULTS From 2005 to 2014, an estimated 53,207 (95% CI 49,330-57,085) admissions with TIPS occurred. A diagnosis of malnutrition was present in 11%. In-hospital death post-TIPS occurred in 15.0% versus 10.7% (p value < 0.001) of patients with and without malnutrition, respectively. Patients with malnutrition had longer post-procedural LOS (median 6.7 vs. 2.9 days, p value < 0.001) and greater total hospital charges (median $144,752 vs. $79,781, p value < 0.001) and were more likely to be discharged to a skilled nursing facility (21.6% vs. 9.7%) than patients without malnutrition. Patients with malnutrition had increased odds of mortality (OR 1.31, 95% CI 1.07, 1.59) compared to patients with no malnutrition. CONCLUSION Malnutrition was associated with worse outcomes after TIPS. Further research is needed to understand the mechanism of malnutrition in post-procedure outcomes and the ability of interventions for nutritional optimization to improve outcomes.
Collapse
Affiliation(s)
- Ryan S Chiang
- Duke University School of Medicine, 2530 Erwin Road APT 254, Durham, NC, 27705, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, DUMC 2721, Durham, NC, 27710, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, DUMC 2721, Durham, NC, 27710, USA.,Duke Cancer Institute-Biostatistics, Hock Plaza I, 2424 Erwin Rd, Suite 802, Room 8040, Durham, NC, 27705, USA
| | - Matthew R Kappus
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC 3923, Durham, NC, 27710, USA
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC 3923, Durham, NC, 27710, USA. .,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
| |
Collapse
|
27
|
Bischoff SC, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, Plauth M. ESPEN practical guideline: Clinical nutrition in liver disease. Clin Nutr 2020; 39:3533-3562. [PMID: 33213977 DOI: 10.1016/j.clnu.2020.09.001] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Practical guideline is based on the current scientific ESPEN guideline on Clinical Nutrition in Liver Disease. METHODS It has been shortened and transformed into flow charts for easier use in clinical practice. The guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with chronic liver disease. RESULTS A total of 103 statements and recommendations are presented with short commentaries for the nutritional and metabolic management of patients with (i) acute liver failure, (ii) alcoholic steatohepatitis, (iii) non-alcoholic fatty liver disease, (iv) liver cirrhosis, and (v) liver surgery/transplantation. The disease-related recommendations are preceded by general recommendations on the diagnostics of nutritional status in liver patients and on liver complications associated with medical nutrition. CONCLUSION This practical guideline gives guidance to health care providers involved in the management of liver disease to offer optimal nutritional care.
Collapse
Affiliation(s)
- Stephan C Bischoff
- Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany.
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Lindsay D Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Tatjana Schütz
- IFB Adiposity Diseases, Leipzig University Medical Centre, Leipzig, Germany
| | - Mathias Plauth
- Department of Internal Medicine, Municipal Hospital of Dessau, Dessau, Germany
| |
Collapse
|
28
|
Schultheiß M, Bettinger D, Thimme R, Rössle M. 30 Jahre transjugulärer intrahepatischer portosystemischer Shunt (TIPS) – Rückblick und Perspektive. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 58:877-889. [DOI: 10.1055/a-1217-7866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ZusammenfassungDer transjuguläre intrahepatische portosystemische Shunt (TIPS) wird seit 30 Jahren in der Therapie der portalen Hypertonie erfolgreich eingesetzt. In nationalen und internationalen Leitlinien ist die Indikation zur TIPS-Anlage bei Varizenblutung und refraktärem Aszites wissenschaftlich gut belegt und klar definiert. Bei seltenen Indikationen wie dem hepatorenalen Syndrom, der Pfortaderthrombose oder dem neoadjuvanten Einsatz fehlt derzeit noch eine eindeutige Studienlage. Eine wichtige Kontraindikation und klinisch bedeutendste Komplikation nach TIPS ist die hepatische Enzephalopathie (HE). Es wird versucht, die Post-TIPS HE mit technischen Weiterentwicklungen der Stents zu reduzieren.
Collapse
Affiliation(s)
- Michael Schultheiß
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Dominik Bettinger
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Robert Thimme
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Martin Rössle
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| |
Collapse
|
29
|
Santos BC, Correia MITD, Anastácio LR. Energy Expenditure and Liver Transplantation: What We Know and Where We Are. JPEN J Parenter Enteral Nutr 2020; 45:456-464. [DOI: 10.1002/jpen.1985] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Bárbara Chaves Santos
- Food Science Post Graduation Program Universidade Federal de Minas Gerais Belo Horizonte Brazil
| | - Maria Isabel Toulson Davisson Correia
- Food Science Post Graduation Program Universidade Federal de Minas Gerais Belo Horizonte Brazil
- Surgery Department Universidade Federal de Minas Gerais Belo Horizonte Brazil
| | - Lucilene Rezende Anastácio
- Food Science Post Graduation Program Universidade Federal de Minas Gerais Belo Horizonte Brazil
- Food Science Department Universidade Federal de Minas Gerais Belo Horizonte Brazil
| |
Collapse
|
30
|
García-Pagán JC, Saffo S, Mandorfer M, Garcia-Tsao G. Where does TIPS fit in the management of patients with cirrhosis? JHEP Rep 2020; 2:100122. [PMID: 32671331 PMCID: PMC7347999 DOI: 10.1016/j.jhepr.2020.100122] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/20/2020] [Accepted: 05/11/2020] [Indexed: 02/06/2023] Open
Abstract
In this review, we summarise the current knowledge on the indications and contraindications of transjugular intrahepatic portosystemic shunt (TIPS) placement for the treatment of the complications of portal hypertension in cirrhosis, specifically variceal haemorrhage and ascites. Moreover, we discuss the role of TIPS for the treatment of portal vein thrombosis (PVT) and the prevention of complications after extrahepatic surgery ('preoperative TIPS') in patients with cirrhosis. The position of TIPS in the treatment hierarchy depends on the clinical setting and on patient characteristics. In acute variceal haemorrhage, preemptive TIPS is indicated in patients at a high risk of failing standard therapy, that is those with a Child-Pugh score of 10-13 points or Child-Pugh B with active bleeding at endoscopy, although the survival benefit in the latter group still remains to be established. Non-preemptive TIPS is a second-line therapy for the prevention of recurrent variceal haemorrhage and for the treatment of ascites. Of note, TIPS may also improve sarcopenia. Contraindications to TIPS placement, independent of clinical setting, include very advanced disease (Child-Pugh >13 points), episodes of recurrent overt hepatic encephalopathy without an identifiable precipitating factor, heart failure, and pulmonary hypertension. In patients with PVT, TIPS placement not only controls complications of portal hypertension, but also promotes portal vein recanalisation. Although the severity of portal hypertension correlates with poor outcomes after extrahepatic surgery, there is no evidence to recommend preoperative TIPS placement.
Collapse
Key Words
- ACLF, acute-on-chronic liver failure
- AKI, acute kidney injury
- ARR, absolute risk reduction
- AVB, acute variceal bleeding
- Ascites
- BNP, brain natriuretic peptide
- BRTO, balloon-occluded retrograde transvenous obliteration
- Bleeding
- CHF, chronic heart failure
- CLD, chronic liver disease
- CSPH, clinically significant portal hypertension
- Cirrhosis
- EVL, endoscopic variceal ligation
- GOV, gastro-oesophageal varices
- HCC, hepatocellular carcinoma
- HE, hepatic encephalopathy
- HVPG, hepatic venous pressure gradient
- Haemorrhage
- ICA, International Club of Ascites
- IGV, isolated gastric varices
- INR, international normalised ratio
- ISMN, isosorbide mononitrate
- LVP+A, LVP with albumin
- LVP, large-volume paracenteses
- MELD, model for end-stage liver disease
- NNT, number needed to treat
- NSBB, non-selective beta blocker
- OS, overall survival
- PCI, percutaneous coronary intervention
- PFTE, polytetrafluoroethylene
- PLT, platelet count
- PSE, portosystemic encephalopathy
- PV, portal vein
- PVT, portal vein thrombosis
- Portal hypertension
- Portal vein thrombosis
- RA, refractory ascites
- RCTs, randomised controlled trials
- SBP, spontaneous bacterial peritonitis
- SEMS, self-expandable metallic stent
- TFS, transplant-free survival
- TIPS, transjugular intrahepatic portosystemic shunt
- Transjugular intrahepatic portosystemic shunt
Collapse
Affiliation(s)
- Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Saad Saffo
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Mattias Mandorfer
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, VA-Connecticut Healthcare System, West Haven, CT, USA
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
31
|
Ehlers L, Bannert K, Rohde S, Berlin P, Reiner J, Wiese M, Doller J, Lerch MM, Aghdassi AA, Meyer F, Valentini L, Agrifoglio O, Metges CC, Lamprecht G, Jaster R. Preclinical insights into the gut-skeletal muscle axis in chronic gastrointestinal diseases. J Cell Mol Med 2020; 24:8304-8314. [PMID: 32628812 PMCID: PMC7412689 DOI: 10.1111/jcmm.15554] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/14/2020] [Indexed: 02/06/2023] Open
Abstract
Muscle wasting represents a constant pathological feature of common chronic gastrointestinal diseases, including liver cirrhosis (LC), inflammatory bowel diseases (IBD), chronic pancreatitis (CP) and pancreatic cancer (PC), and is associated with increased morbidity and mortality. Recent clinical and experimental studies point to the existence of a gut‐skeletal muscle axis that is constituted by specific gut‐derived mediators which activate pro‐ and anti‐sarcopenic signalling pathways in skeletal muscle cells. A pathophysiological link between both organs is also provided by low‐grade systemic inflammation. Animal models of LC, IBD, CP and PC represent an important resource for mechanistic and preclinical studies on disease‐associated muscle wasting. They are also required to test and validate specific anti‐sarcopenic therapies prior to clinical application. In this article, we review frequently used rodent models of muscle wasting in the context of chronic gastrointestinal diseases, survey their specific advantages and limitations and discuss possibilities for further research activities in the field. We conclude that animal models of LC‐, IBD‐ and PC‐associated sarcopenia are an essential supplement to clinical studies because they may provide additional mechanistic insights and help to identify molecular targets for therapeutic interventions in humans.
Collapse
Affiliation(s)
- Luise Ehlers
- Department of Medicine II, Division of Gastroenterology, Rostock University Medical Center, Rostock, Germany
| | - Karen Bannert
- Department of Medicine II, Division of Gastroenterology, Rostock University Medical Center, Rostock, Germany
| | - Sarah Rohde
- Department of Medicine II, Division of Gastroenterology, Rostock University Medical Center, Rostock, Germany
| | - Peggy Berlin
- Department of Medicine II, Division of Gastroenterology, Rostock University Medical Center, Rostock, Germany
| | - Johannes Reiner
- Department of Medicine II, Division of Gastroenterology, Rostock University Medical Center, Rostock, Germany
| | - Mats Wiese
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Julia Doller
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Markus M Lerch
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Ali A Aghdassi
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Fatuma Meyer
- Department of Agriculture and Food Sciences, Neubrandenburg Institute of Evidence-Based Nutrition (NIED), University of Applied Sciences Neubrandenburg, Neubrandenburg, Germany
| | - Luzia Valentini
- Department of Agriculture and Food Sciences, Neubrandenburg Institute of Evidence-Based Nutrition (NIED), University of Applied Sciences Neubrandenburg, Neubrandenburg, Germany
| | - Ottavia Agrifoglio
- Institute of Nutritional Physiology 'Oskar Kellner', Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany
| | - Cornelia C Metges
- Institute of Nutritional Physiology 'Oskar Kellner', Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany
| | - Georg Lamprecht
- Department of Medicine II, Division of Gastroenterology, Rostock University Medical Center, Rostock, Germany
| | - Robert Jaster
- Department of Medicine II, Division of Gastroenterology, Rostock University Medical Center, Rostock, Germany
| |
Collapse
|
32
|
Allaire M, Walter A, Sutter O, Nahon P, Ganne-Carrié N, Amathieu R, Nault JC. TIPS for management of portal-hypertension-related complications in patients with cirrhosis. Clin Res Hepatol Gastroenterol 2020; 44:249-263. [PMID: 31662286 DOI: 10.1016/j.clinre.2019.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 08/25/2019] [Accepted: 09/13/2019] [Indexed: 02/04/2023]
Abstract
Portal hypertension is primarily due to liver cirrhosis, and is responsible for complications that include variceal bleeding, ascites and hepatorenal syndrome. The transjugular intrahepatic portosystemic shunt (TIPS) is a low-resistance channel between the portal vein and the hepatic vein, created by interventional radiology, that aims to reduce portal pressure. TIPS is a potential treatment for severe portal-hypertension-related complications, including esophageal and gastric variceal bleeding. TIPS is currently indicated as salvage therapy in this setting when patients fail to respond to standard endoscopic and medical treatment. More recently, early TIPS has been shown to be effective in decreasing risk of rebleeding after variceal hemorrhage and mortality in Child-Pugh B patients with active hemorrhage at endoscopy, and in Child-Pugh C patients. TIPS is also an efficient treatment for refractory ascites and hepatic hydrothorax. In contrast, the role of TIPS in the hepatorenal syndrome has not been precisely defined. The aim of this review was to specifically describe the current role of TIPS in management of portal hypertension in patients with cirrhosis.
Collapse
Affiliation(s)
- Manon Allaire
- Service d'hépato-gastroentérologie, CHU Côte-de-Nacre, Caen, France
| | - Aurélie Walter
- Service d'hépato-gastroentérologie, CHU Côte-de-Nacre, Caen, France
| | - Olivier Sutter
- Service de radiologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique Hôpitaux de Paris, Bondy, France
| | - Pierre Nahon
- Service d'hépatologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, 93143 Bondy, France; Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris 13, Laboratoire génomique fonctionnelle des tumeurs solides, 75006 Paris, France; Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France
| | - Nathalie Ganne-Carrié
- Service d'hépatologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, 93143 Bondy, France; Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris 13, Laboratoire génomique fonctionnelle des tumeurs solides, 75006 Paris, France; Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France
| | - Roland Amathieu
- Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France; Réanimation polyvalente, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, Bondy, France
| | - Jean-Charles Nault
- Service d'hépatologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, 93143 Bondy, France; Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris 13, Laboratoire génomique fonctionnelle des tumeurs solides, 75006 Paris, France; Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France.
| |
Collapse
|
33
|
Vizzutti F, Schepis F, Arena U, Fanelli F, Gitto S, Aspite S, Turco L, Dragoni G, Laffi G, Marra F. Transjugular intrahepatic portosystemic shunt (TIPS): current indications and strategies to improve the outcomes. Intern Emerg Med 2020; 15:37-48. [PMID: 31919780 DOI: 10.1007/s11739-019-02252-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/03/2019] [Indexed: 12/16/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) represents a very effective treatment of complications of portal hypertension. Established indications to TIPS in cirrhotic patients include portal hypertensive bleeding and refractory ascites. Over the years additional indications have been proposed, such as the treatment of vascular disease of the liver, hepatic hydrothorax, hepatorenal syndrome and bleeding from ectopic varices. Indications under evaluation include treatment of portal hypertension prior to major abdominal surgery and treatment of portal vein thrombosis. In spite of these advances, there are still uncertainties regarding the appropriate workup for patients to be scheduled for TIPS. Moreover, prevention and management of post-TIPS complications including hepatic encephalopathy and heart failure are still suboptimal. These issues are particularly relevant considering aging in TIPS candidates in Western countries. Correct selection of patients is mandatory to prevent complications which may eventually frustrate the good hemodynamic results and worsen the patient's quality of life or even life expectancy. The possible role of small diameter TIPS to prevent post-procedural complications is discussed.
Collapse
Affiliation(s)
- Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Filippo Schepis
- Department of Internal Medicine, University of Modena and Reggio, Modena, Italy
| | - Umberto Arena
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Fabrizio Fanelli
- Department of Radiology, Interventional Radiology, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Silvia Aspite
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Laura Turco
- Department of Internal Medicine, University of Modena and Reggio, Modena, Italy
| | - Gabriele Dragoni
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Giacomo Laffi
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy.
- Center for Research, High Education and Transfer DENOThe, University of Florence, Florence, Italy.
| |
Collapse
|
34
|
Abstract
Sarcopenia, frailty, and malnutrition are prevalent complications in patients with end-stage liver disease (ESLD) and are associated with increased risk of morbidity and mortality. It is valuable to measure nutritional status, sarcopenia, and frailty over time in order to create interventions tailored to individuals with ESLD. Evaluating sarcopenia and frailty in patients with ESLD is challenging. Further work is needed to perfect these assessments so that clinicians can incorporate these assessments into their decision-making and management plans for cirrhotic patients.
Collapse
Affiliation(s)
- Elizabeth S Aby
- Department of Medicine, University of California at Los Angeles, UCLA Medical Center, 757 Westwood Plaza, Suite 7501, Los Angeles, CA 90095, USA. https://twitter.com/lizabmn47
| | - Sammy Saab
- Department of Medicine, University of California at Los Angeles, UCLA Medical Center, 757 Westwood Plaza, Suite 7501, Los Angeles, CA 90095, USA; Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA.
| |
Collapse
|
35
|
Lattanzi B, Gioia S, Di Cola S, D'Ambrosio D, Nardelli S, Tavano D, Farcomeni A, Merli M, Riggio O. Prevalence and impact of sarcopenia in non-cirrhotic portal hypertension. Liver Int 2019; 39:1937-1942. [PMID: 31152475 DOI: 10.1111/liv.14160] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/16/2019] [Accepted: 05/20/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Little is known on nutritional parameters in patients with chronic portal vein thrombosis (PVT) and idiopathic non-cirrhotic portal hypertension (INCPH). The study aims to assess the prevalence and the clinical impact of sarcopenia in patients with non-cirrhotic portal hypertension (NCPH). A control group of cirrhotic patients was also studied. Both groups were followed up to establish the relationship between sarcopenia and clinical outcomes. METHODS Sixty-seven patients with NCPH (51 PVT and 16 INCPH) were included in the study group and 104 patients with liver cirrhosis in the control group. The axial plane passing through the intersomatic disk between L3 and L4 was evaluated for the quantitative analysis of muscle mass and the skeletal muscle index (SMI) was calculated. The presence of sarcopenia was established according to SMI validated cut off. RESULTS Sarcopenia was present in the 38% of patients with INCPH, 35% of patients with chronic PVT, 32% of patients with compensated cirrhosis and 54% of decompensated cirrhotics. During a mean follow-up of 51 ± 62 months, there was no difference in sarcopenic and non-sarcopenic patients with NCPH for incidence of ascites, hepatic encephalopathy, esophageal varices, variceal bleeding and death. However, the incidence of refractory variceal bleeding requiring TIPS placement was significantly higher in comparison with the non-sarcopenic ones (29% vs 7%, P = 0.01 at log-rank test). CONCLUSIONS In patients with NCPH sarcopenia is similar to that observed in cirrhotic patients. Moreover, the rate of refractory variceal bleeding was higher in sarcopenic patients suggesting a clinical negative impact of muscle depletion.
Collapse
Affiliation(s)
- Barbara Lattanzi
- Department of Translational and Precision Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, "Sapienza" University of Rome, Rome, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, "Sapienza" University of Rome, Rome, Italy
| | - Simone Di Cola
- Department of Translational and Precision Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, "Sapienza" University of Rome, Rome, Italy
| | - Daria D'Ambrosio
- Department of Translational and Precision Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, "Sapienza" University of Rome, Rome, Italy
| | - Silvia Nardelli
- Department of Translational and Precision Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, "Sapienza" University of Rome, Rome, Italy
| | - Daniele Tavano
- Department of Translational and Precision Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, "Sapienza" University of Rome, Rome, Italy
| | - Alessio Farcomeni
- Deptartment of Public Health and Infectious Diseases, "Sapienza" University of Rome, Rome, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, "Sapienza" University of Rome, Rome, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, Centre for the Diagnosis and Treatment of Portal Hypertension, "Sapienza" University of Rome, Rome, Italy
| |
Collapse
|
36
|
Chapman B, Gow P, Sinclair M, Hanrahan T, Angus P, McClure T, Mills C, Terbah R, Testro A. Continuous terlipressin infusion is associated with improved diet intake and muscle strength in patients awaiting liver transplant. JHEP Rep 2019; 1:107-113. [PMID: 32039358 PMCID: PMC7001556 DOI: 10.1016/j.jhepr.2019.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/30/2019] [Accepted: 05/08/2019] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Portal hypertension contributes to the pathogenesis of malnutrition and sarcopenia in cirrhosis via multiple mechanisms. Terlipressin is a vasopressin analogue that we administer via continuous outpatient infusion, as a bridge to transplantation in patients with hepatorenal syndrome or refractory ascites. We describe, for the first time, the impact of outpatient terlipressin on nutritional and muscle parameters. Methods Nutrition (subjective global assessment), handgrip strength, dietary intake (energy, protein), frequency of paracentesis and severity of liver disease (model for end-stage liver disease score) were prospectively recorded at terlipressin commencement and follow-up (transplantation, cessation or census date). Results Nineteen patients were included (89% male, median age 59.6 years, median model for end-stage liver disease score 24), of whom 12 had hepatorenal syndrome and 7 had refractory ascites. All patients were malnourished at baseline, 63% (n = 12) had sarcopenic-range grip strength, and mean paracentesis frequency was 2.86 ± 1.62/month. Median duration of terlipressin was 51 days (interquartile range 29–222). Fourteen patients (74%) were transplanted, 2 delisted (10%) and 3 (16%) continued terlipressin. Energy and protein intake improved significantly following terlipressin, from 17.94 ± 5.43 kcal/kg to 27.70 ± 7.48 kcal/kg, and 0.74 ± 0.28 g/kg to 1.16 ± 0.31 g/kg, respectively (both p < 0.001). Handgrip strength increased from 25.36 ± 8.13 kg to 28.49 ± 7.63 kg (p = 0.001). Linear regression analysis demonstrated hand grip strength increased 0.075% for every 1-day of terlipressin (p = 0.005). The frequency of large-volume paracentesis reduced by 46%, to 1.57 ± 1.51/month (p = 0.001). Conclusion Continuous terlipressin infusion reduces the complications of portal hypertension and is associated with an improvement in nutritional and muscle parameters in patients on the liver transplant waiting list, in whom such characteristics usually demonstrate progressive decline. This validates both the aetiological role of portal hypertension in malnutrition and represents a promising new anabolic therapy. Lay summary Malnutrition and poor muscle strength are common in liver disease and often get worse while patients await liver transplant. Terlipressin is a medication used to treat portal hypertension in patients with hepatorenal syndrome. It is usually given for a few days or weeks in patients confined to hospital. Our centre provides outpatient terlipressin for weeks to months as a bridge to liver transplant. In patients treated with terlipressin at our hospital, we observed a substantial increase in their dietary intake and muscle strength, which may improve their quality of life and outcomes after liver transplant. Malnutrition and poor muscle strength are highly prevalent in cirrhotics with hepatorenal syndrome. Terlipressin infusion increased energy and protein intake in patients with hepatorenal syndrome. Handgrip strength continued to increase with every day of terlipressin therapy Medium to long-term terlipressin infusion was safe and efficacious as a bridge to liver transplant.
Collapse
Affiliation(s)
- Brooke Chapman
- Department of Nutrition and Dietetics, Austin Health, Heidelberg, Victoria, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Timothy Hanrahan
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Peter Angus
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Tess McClure
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Chris Mills
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Ryma Terbah
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Adam Testro
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
| |
Collapse
|
37
|
Eslamparast T, Vandermeer B, Raman M, Gramlich L, Den Heyer V, Belland D, Ma M, Tandon P. Are Predictive Energy Expenditure Equations Accurate in Cirrhosis? Nutrients 2019; 11:nu11020334. [PMID: 30720726 PMCID: PMC6412603 DOI: 10.3390/nu11020334] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 01/27/2019] [Accepted: 01/28/2019] [Indexed: 02/06/2023] Open
Abstract
Malnutrition is associated with significant morbidity and mortality in cirrhosis. An accurate nutrition prescription is an essential component of care, often estimated using time-efficient predictive equations. Our aim was to compare resting energy expenditure (REE) estimated using predictive equations (predicted REE, pREE) versus REE measured using gold-standard, indirect calorimetry (IC) (measured REE, mREE). We included full-text English language studies in adults with cirrhosis comparing pREE versus mREE. The mean differences across studies were pooled with RevMan 5.3 software. A total of 17 studies (1883 patients) were analyzed. The pooled cohort was comprised of 65% men with a mean age of 53 ± 7 years. Only 45% of predictive equations estimated energy requirements to within 90⁻110% of mREE using IC. Eighty-three percent of predictive equations underestimated and 28% overestimated energy needs by ±10%. When pooled, the mean difference between the mREE and pREE was lowest for the Harris⁻Benedict equation, with an underestimation of 54 (95% CI: 30⁻137) kcal/d. The pooled analysis was associated with significant heterogeneity (I2 = 94%). In conclusion, predictive equations calculating REE have limited accuracy in patients with cirrhosis, most commonly underestimating energy requirements and are associated with wide variations in individual comparative data.
Collapse
Affiliation(s)
- Tannaz Eslamparast
- Department of Medicine, University of Alberta, 130 University Campus, Zeidler ledcor Centre, Edmonton, AB T6G 2X8, Canada.
| | - Benjamin Vandermeer
- Alberta Research Center for Health Evidence, Pediatrics, 4-496 Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB T6G 1C9, Canada.
| | - Maitreyi Raman
- Department of Medicine, University of Calgary, 6D26 TRW Building 3280 Hospital drive NW, Calgary, AB T2N 4N1, Canada.
| | - Leah Gramlich
- Department of Medicine, Royal Alexandra Hospital, University of Alberta, Edmonton, AB T5H 3V9, Canada.
| | - Vanessa Den Heyer
- Alberta Health Services Nutrition Services, University of Alberta Hospital, Edmonton, AB T5H 3V9, Canada.
| | - Dawn Belland
- Alberta Health Services Nutrition Services, University of Alberta Hospital, Edmonton, AB T5H 3V9, Canada.
| | - Mang Ma
- Department of Medicine, University of Alberta, 130 University Campus, Zeidler ledcor Centre, Edmonton, AB T6G 2X8, Canada.
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, 130 University Campus, Zeidler ledcor Centre, Edmonton, AB T6G 2X8, Canada.
| |
Collapse
|
38
|
Naseer M, Turse EP, Syed A, Dailey FE, Zatreh M, Tahan V. Interventions to improve sarcopenia in cirrhosis: A systematic review. World J Clin Cases 2019; 7:156-170. [PMID: 30705893 PMCID: PMC6354093 DOI: 10.12998/wjcc.v7.i2.156] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Sarcopenia, i.e., muscle loss is now a well-recognized complication of cirrhosis and in cases of non-alcoholic fatty liver disease can contribute to accelerate liver fibrosis leading to cirrhosis. Hence, it is imperative to study interventions which targets to improve sarcopenia in cirrhosis.
AIM To examine the relationship between interventions such nutritional supplementation, exercise, combined life style intervention, testosterone replacement and trans jugular intrahepatic portosystemic shunt (TIPS) to improve muscle mass in cirrhosis.
METHODS We search PubMed, EMBASE and Cochrane between June-August 2018, without a limiting period and the types of articles (RCTs, clinical trial, comparative study) in adult patients with sarcopenia and cirrhosis. The primary outcome of interest was improvement in muscle mass, strength and physical function interventions mentioned above. In the screening process, 154 full text articles were included in the review and 129 studies were excluded.
RESULTS We identified 24 studies that met review inclusion criteria. The studies were diverse in terms of the design, setting, interventions, and outcome measurements. We performed only qualitative synthesis of evidence due to heterogeneity amongst studies. Risk of bias was medium in most of the included studies and low quality of evidence showed improvement in the muscle mass, strength and physical function following aerobic exercise. 60% of the included studies on the nutritional intervention, 100% of the studies on testosterone replacement in hypogonadal men and trans-jugular portosystemic shunt were proved to be effective in improving sarcopenia in cirrhosis.
CONCLUSION Although the quality of evidence is low, the findings of our systematic review suggest improvement in the sarcopenia in cirrhosis with exercise, nutritional interventions, hormonal and TIPS interventions. High quality randomized controlled trials needed to further strengthen these findings.
Collapse
Affiliation(s)
- Maliha Naseer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, East Carolina University, Greenville, NC 27834, United States
| | - Erica P Turse
- Department of Internal Medicine, Division of Gastroenterology, St Joseph Hospital Medical Center/Creighton University, Phoenix, AZ 85013, United States
| | - Ali Syed
- Department of Internal Medicine, University of Missouri, Columbia, MO 65212, United States
| | - Francis E Dailey
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Missouri, Columbia, MO 65212, United States
| | - Mallak Zatreh
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Missouri, Columbia, MO 65212, United States
| | - Veysel Tahan
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Missouri, Columbia, MO 65212, United States
| |
Collapse
|
39
|
Plauth M, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, Bischoff SC. ESPEN guideline on clinical nutrition in liver disease. Clin Nutr 2019; 38:485-521. [PMID: 30712783 DOI: 10.1016/j.clnu.2018.12.022] [Citation(s) in RCA: 335] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 02/06/2023]
Abstract
This update of evidence-based guidelines (GL) aims to translate current evidence and expert opinion into recommendations for multidisciplinary teams responsible for the optimal nutritional and metabolic management of adult patients with liver disease. The GL was commissioned and financially supported by ESPEN. Members of the guideline group were selected by ESPEN. We searched for meta-analyses, systematic reviews and single clinical trials based on clinical questions according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing the SIGN method. A total of 85 recommendations were made for the nutritional and metabolic management of patients with acute liver failure, severe alcoholic steatohepatitis, non-alcoholic fatty liver disease, liver cirrhosis, liver surgery and transplantation as well as nutrition associated liver injury distinct from fatty liver disease. The recommendations are preceded by statements covering current knowledge of the underlying pathophysiology and pathobiochemistry as well as pertinent methods for the assessment of nutritional status and body composition.
Collapse
Affiliation(s)
- Mathias Plauth
- Department of Internal Medicine, Municipal Hospital of Dessau, Dessau, Germany.
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Lindsay D Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Tatjana Schütz
- IFB Adiposity Diseases, Leipzig University Medical Centre, Leipzig, Germany
| | - Stephan C Bischoff
- Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany
| |
Collapse
|
40
|
Plauth M. Nutritional Intervention in Chronic Liver Failure. Visc Med 2019; 35:292-298. [DOI: 10.1159/000502125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/09/2019] [Indexed: 12/14/2022] Open
Abstract
Patients suffering from chronic liver failure (CLF) frequently are malnourished and do not achieve an adequate intake of nutrients, in particular protein. Low protein intake and loss of muscle mass and function, termed sarcopenia, are indicators of a poor outcome. CLF patients, therefore, should be screened for risk of malnutrition using a validated tool, and if positive, full assessment of nutritional status is mandatory including search for sarcopenia. The main goal of nutritional intervention is to provide enough protein (1.2–1.5 g × kg<sup>–1</sup> × day<sup>–1</sup>) and to ensure adequate energy intake (total energy 30 kcal × kg<sup>–1</sup> × day<sup>–1</sup>; 1.3 × resting energy expenditure). Livers of CLF patients are deplete in glycogen and, therefore, prolonged periods of fasting (>12 h) must be avoided in order to prevent further breakdown of muscle protein for gluconeogenesis. Therefore, late evening snacks or even nocturnal oral nutritional supplements improve total body protein status and thus, are recommended. Nutrition intervention should be stepped up from nutrition counselling to oral nutritional supplements, to enteral tube feeding, or to parenteral nutrition as appropriate. As in other malnourished patients, the prevention of refeeding syndrome or vitamin/trace element deficiency should be taken care of.
Collapse
|
41
|
Abstract
AIM Acute post liver transplant (LT) phase is characterized by hypermetabolism and increased nutrient requirements. This study aimed to provide the cardinal data on nutrition progression in the management of acute post-LT patients. METHODS This exploratory study recruited 54 adult acute post-LT recipients. The information regarding patient stay, weight status, biochemical parameters, and route of feeding was gathered. Recipients' dietary and nutrient intake was computed by 24-h dietary recall method. RESULTS The data exhibited a significant trend of lower hemoglobin, platelet, and albumin levels and increased bilirubin (T), alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transferase levels (P < 0.05). In acute post-LT patients, a significant decrease in weight status (P < 0.001*) was observed. The recipients' information on daily nutrition progression showed significantly lower intake of calorie, protein, fats, calcium (P < 0.05) and lower percentage adequacy of other nutrients as compared to the recommended guidelines. The energy and protein intake from the parenteral route of feeding significantly decreased and that of through oral route significantly increased (P < 0.05) from postoperative day (POD) 2 to POD 9 and POD 12. CONCLUSION There are scant data on nutrition management in acute post-LT phase. The present study provides the framework for the formulation of continuous, patient-centric, aggressive nutrition management interventions for acute post-LT recipients.
Collapse
Affiliation(s)
- Neha Bakshi
- Department of Food and Nutrition, Lady Irwin College, University of Delhi, New Delhi, India
| | - Kalyani Singh
- Department of Food and Nutrition, Lady Irwin College, University of Delhi, New Delhi, India
| |
Collapse
|
42
|
EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1549] [Impact Index Per Article: 258.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
|
43
|
Duarte-Rojo A, Ruiz-Margáin A, Montaño-Loza AJ, Macías-Rodríguez RU, Ferrando A, Kim WR. Exercise and physical activity for patients with end-stage liver disease: Improving functional status and sarcopenia while on the transplant waiting list. Liver Transpl 2018; 24:122-139. [PMID: 29024353 DOI: 10.1002/lt.24958] [Citation(s) in RCA: 127] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 09/05/2017] [Accepted: 09/09/2017] [Indexed: 12/20/2022]
Abstract
Sarcopenia and physical deconditioning are frequent complications in patients with cirrhosis and end-stage liver disease (ESLD). They are the end result of impaired dietary intake, chronic inflammation, altered macronutrient and micronutrient metabolism, and low physical activity. Frailty is the end result of prolonged sarcopenia and physical deconditioning. It severely affects a patient's functional status and presents in approximately 1 in 5 patients on the liver transplantation waiting list. Sarcopenia, poor physical fitness/cardiopulmonary endurance (CPE), and frailty are all associated with increased mortality in ESLD. Clinical trials addressing the usefulness of exercise in patients with cirrhosis have shown that it improves the metabolic syndrome, sarcopenia, CPE, health-related quality of life, and hepatic venous pressure gradient. Although evidence on the benefits of exercise on clinical outcomes derived from large clinical trials is still missing, based on existing literature from multiple medical subspecialties, we believe that an exercise program coupled to a tailored nutritional intervention benefits both cardiopulmonary and musculoskeletal functions, ultimately translating into improved functional status, sense of well-being, and possibly less complications from portal hypertension. In conclusion, although supervised exercise training is the prevailing approach to manage ESLD patients, such intervention is not sustainable or feasible for most patients. Innovative home-based physical activity interventions may be able to effectively reach a larger number of patients. Liver Transplantation 24 122-139 2018 AASLD.
Collapse
Affiliation(s)
| | - Astrid Ruiz-Margáin
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán,", Mexico City, Mexico
| | - Aldo J Montaño-Loza
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Canada
| | - Ricardo U Macías-Rodríguez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán,", Mexico City, Mexico
| | - Arny Ferrando
- Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford School of Medicine, Stanford, CA
| |
Collapse
|
44
|
Bureau C, Adebayo D, Chalret de Rieu M, Elkrief L, Valla D, Peck-Radosavljevic M, McCune A, Vargas V, Simon-Talero M, Cordoba J, Angeli P, Rosi S, MacDonald S, Malago M, Stepanova M, Younossi ZM, Trepte C, Watson R, Borisenko O, Sun S, Inhaber N, Jalan R. Alfapump® system vs. large volume paracentesis for refractory ascites: A multicenter randomized controlled study. J Hepatol 2017. [PMID: 28645737 DOI: 10.1016/j.jhep.2017.06.010] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Patients with refractory ascites (RA) require repeated large volume paracenteses (LVP), which involves frequent hospital visits and is associated with a poor quality-of-life. This study assessed safety and efficacy of an automated, low-flow pump (alfapump® [AP]) compared with LVP standard of care [SoC]. METHODS A randomized controlled trial, in seven centers, with six month patient observation was conducted. Primary outcome was time to first LVP. Secondary outcomes included paracentesis requirement, safety, health-related quality-of-life (HRQoL), and survival. Nutrition, hemodynamics, and renal injury biomarkers were assessed in a sub-study at three months. RESULTS Sixty patients were randomized and 58 were analyzed (27 AP, 31 SoC, mean age 61.9years, mean MELD 11.7). Eighteen patients were included in the sub-study. Compared with SoC, median time to first LVP was not reached after six months in the AP group, meaning a significant reduction in LVP requirement for the AP patients (AP, median not reached; SoC, 15.0days (HR 0.13; 95%CI 13.0-22.0; p<0.001), and AP patients also showed significantly improved Chronic Liver Disease Questionnaire (CLDQ) scores compared with SoC patients (p<0.05 between treatment arms). Improvements in nutritional parameters were observed for hand-grip strength (p=0.044) and body mass index (p<0.001) in the sub-study. Compared with SoC, more AP patients reported adverse events (AEs; 96.3% vs. 77.4%, p=0.057) and serious AEs (85.2 vs. 45.2%, p=0.002). AEs consisted predominantly of acute kidney injury in the immediate post-operative period, and re-intervention for pump related issues, and were treatable in most cases. Survival was similar in AP and SoC. CONCLUSIONS The AP system is effective for reducing the need for paracentesis and improving quality of life in cirrhotic patients with RA. Although the frequency of SAEs (and by inference hospitalizations) was significantly higher in the AP group, they were generally limited and did not impact survival. Lay summary: The alfapump® moves abdominal fluid into the bladder from where it is then removed by urination. Compared with standard treatment, the alfapump reduces the need for large volume paracentesis (manual fluid removal by needle) in patients with medically untreatable ascites. This can improve life quality for these patients. www.clinicaltrials.gov#NCT01528410.
Collapse
Affiliation(s)
| | - Danielle Adebayo
- UCL Institute of Hepatology, Royal Free Hospital, University College London, London, United Kingdom
| | | | - Laure Elkrief
- DHU UNITY, Service d'hépatologie, Hôpital Beaujon, Clichy and Université Paris Diderot and Inserm U1149, Paris, France
| | - Dominique Valla
- DHU UNITY, Service d'hépatologie, Hôpital Beaujon, Clichy and Université Paris Diderot and Inserm U1149, Paris, France
| | - Markus Peck-Radosavljevic
- Department of Gastroenterology/Hepatology, Endocrinology and Nephrology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Anne McCune
- Department of Hepatology, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Victor Vargas
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, VHIR, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Macarena Simon-Talero
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, VHIR, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Juan Cordoba
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, VHIR, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Paolo Angeli
- Facoltà di Medicina e Chirurgia, Università degli Studi di Padova, Padova, Italy
| | - Silvia Rosi
- Facoltà di Medicina e Chirurgia, Università degli Studi di Padova, Padova, Italy
| | - Stewart MacDonald
- UCL Institute of Hepatology, Royal Free Hospital, University College London, London, United Kingdom
| | - Massimo Malago
- Hepato-pancreatic-biliary and Liver Transplantation Surgery, Royal Free Hospital, University College London, London, United Kingdom
| | - Maria Stepanova
- Center for Outcomes Research in Liver Disease, Washington DC, United States
| | - Zobair M Younossi
- Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, United States
| | | | | | | | - Sun Sun
- Synergus AB, Danderyd, Sweden; Health Outcomes and Economic Evaluation Research Group, Department of Learning, Information, Management and Ethics, Karolinska Institutet, Stockholm, Sweden; Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | | | - Rajiv Jalan
- UCL Institute of Hepatology, Royal Free Hospital, University College London, London, United Kingdom.
| |
Collapse
|
45
|
Nutritional status, energy expenditure, and protein oxidative stress after kidney transplantation. Redox Rep 2017; 22:439-444. [PMID: 28498788 DOI: 10.1080/13510002.2017.1325572] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES To evaluate the association between nutritional status, resting energy expenditure (REE), and protein oxidative stress in patients after kidney transplantation (KT). METHODOLOGY The study evaluated 35 patients transplanted at the time of hospital discharge and 3 months after regarding: body composition, REE (by indirect calorimetry), and injury factor (IF); serum urea, creatinine, glucose, albumin, total protein, advanced oxidation protein products (AOPP), vitamin C. RESULTS Three months after discharge, there was an improvement in renal function, nutritional status, and oxidative stress, with a standardization in the REE/kg. There was an increase in body weight, mainly in fat mass. The correlations showed that a greater cold ischemia time resulted in a deeper decline in vitamin C; a longer hospital length stay resulted in a greater reduction in AOPP; the higher preoperative body weight showed greater increases in body fat and glucose after transplantation. For decreases in REE and IF, there were increases in total protein. Finally, at hospital discharge there was a greater gain in weight, lower albumin, and total protein among individuals who had rejection episodes. DISCUSSION The KT improves many of metabolic abnormalities, with the improvement of nutritional status, oxidative stress, and normalization of REE.
Collapse
|
46
|
Bureau C, Thabut D, Oberti F, Dharancy S, Carbonell N, Bouvier A, Mathurin P, Otal P, Cabarrou P, Péron JM, Vinel JP. Transjugular Intrahepatic Portosystemic Shunts With Covered Stents Increase Transplant-Free Survival of Patients With Cirrhosis and Recurrent Ascites. Gastroenterology 2017; 152:157-163. [PMID: 27663604 DOI: 10.1053/j.gastro.2016.09.016] [Citation(s) in RCA: 266] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 09/14/2016] [Accepted: 09/14/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS There is controversy over the ability of transjugular intrahepatic portosystemic shunts (TIPS) to increase survival times of patients with cirrhosis and refractory ascites. The high rate of shunt dysfunction with the use of uncovered stents counteracts the benefits of TIPS. We performed a randomized controlled trial to determine the effects of TIPS with stents covered with polytetrafluoroethylene in these patients. METHODS We performed a prospective study of 62 patients with cirrhosis and at least 2 large-volume paracenteses within a period of at least 3 weeks; the study was performed at 4 tertiary care centers in France from August 2005 through December 2012. Patients were randomly assigned to groups that received covered TIPS (n = 29) or large-volume paracenteses and albumin as necessary (LVP+A, n = 33). All patients maintained a low-salt diet and were examined at 1 month after the procedure then every 3 months until 1 year. At each visit, liver disease-related complications, treatment modifications, and clinical and biochemical variables needed to calculate Child-Pugh and Model for End-Stage Liver Disease scores were recorded. Doppler ultrasonography was performed at the start of the study and then at 6 and 12 months after the procedure. The primary study end point was survival without a liver transplant for 1 year after the procedure. RESULTS A higher proportion of patients in the TIPS group (93%) met the primary end point than in the LVP+A group (52%) (P = .003). The total number of paracenteses was 32 in the TIPS group vs 320 in the LVP+A group. Higher proportions of patients in the LVP+A group had portal hypertension-related bleeding (18% vs 0%; P = .01) or hernia-related complications (18% vs 0%; P = .01) than in the TIPS group. Patients in LVP+A group had twice as many days of hospitalization (35 days) as the TIPS group (17 days) (P = .04). The 1-year probability of remaining free of encephalopathy was 65% for each group. CONCLUSIONS In a randomized trial, we found covered stents for TIPS to increase the proportion of patients with cirrhosis and recurrent ascites who survive transplantation-free for 1 year, compared with patients given repeated LVP+A. These findings support TIPS as the first-line intervention in such patients. ClinicalTrials.gov ID: NCT00222014.
Collapse
Affiliation(s)
- Christophe Bureau
- Service d'hépato-gastroentérologie, Hôpital Purpan Centre Hospitalier Universitaire Toulouse, Toulouse Cedex, France; Université Paul Sabatier Toulouse III, Toulouse Cedex, France.
| | | | - Frédéric Oberti
- Centre Hospitalier Universitaire d'Angers, Angers, Pays de la Loire, France
| | - Sébastien Dharancy
- Hôpital Huriez, Service des maladies de l'appareil digestif, Lille, France
| | | | - Antoine Bouvier
- Centre Hospitalier Universitaire d'Angers, Angers, Pays de la Loire, France
| | - Philippe Mathurin
- Hôpital Huriez, Service des maladies de l'appareil digestif, Lille, France
| | - Philippe Otal
- Université Paul Sabatier Toulouse III, Toulouse Cedex, France; Service de Radiologie, Hôpital Rangueil, Centre Hospitalier Universitaire Toulouse, Toulouse Cedex, France
| | - Pauline Cabarrou
- Service d'hépato-gastroentérologie, Hôpital Purpan Centre Hospitalier Universitaire Toulouse, Toulouse Cedex, France
| | - Jean Marie Péron
- Service d'hépato-gastroentérologie, Hôpital Purpan Centre Hospitalier Universitaire Toulouse, Toulouse Cedex, France; Université Paul Sabatier Toulouse III, Toulouse Cedex, France
| | - Jean Pierre Vinel
- Service d'hépato-gastroentérologie, Hôpital Purpan Centre Hospitalier Universitaire Toulouse, Toulouse Cedex, France; Université Paul Sabatier Toulouse III, Toulouse Cedex, France
| |
Collapse
|
47
|
Rathi S, Dhiman RK. Hepatobiliary Quiz Answers - 18 (2016). J Clin Exp Hepatol 2016; 6:159-63. [PMID: 27493465 PMCID: PMC4963321 DOI: 10.1016/j.jceh.2016.06.174] [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: 12/12/2022] Open
Affiliation(s)
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| |
Collapse
|
48
|
Abstract
Background Understanding of the gut-liver axis is important for the up-to-date management of liver cirrhosis, and changes of intestinal functions form the core of this interesting research field. Summary Most investigators noted small intestinal dysmotility in their patients with liver cirrhosis. Marked changes in the contraction pattern were observed in early manometric studies. The orocecal transit time, particularly small intestinal transit, has generally been reported to be prolonged, which has been demonstrated in multiple investigations to be related to the severity of the liver disease (e.g., Child-Pugh class), the presence of small intestinal bacterial overgrowth (SIBO) and hepatic encephalopathy (HE) as well as a history of spontaneous bacterial peritonitis. Bacteriologically proven SIBO in proximal jejunal aspiration has been reported to be present in up to 59% of cirrhotic patients and is associated with systemic endotoxemia. Clinical and experimental studies suggest that delayed small bowel transit in liver cirrhosis may lead to SIBO, which could contribute to the symptoms of abdominal pain and diarrhea. In addition to autonomic neuropathy, metabolic derangements and diabetic state, SIBO itself may delay intestinal transit in cirrhotic patients. Several studies, both from the West and the East, have shown that the gut microbiota is altered in cirrhotic patients and particularly those with HE. Further, a quantitative change in Bacteroides/Firmicutes ratio, with a prevalence of potentially pathogenic bacteria (e.g., Enterobacteriaceae) and reduction in specific commensals (e.g., Lachnospiraceae), has been described. Structural and functional changes in the intestinal mucosa that contribute to increases in intestinal permeability for bacteria and their products have been observed in patients with liver cirrhosis, which is considered as an important pathogenetic factor for several complications. The mechanism of intestinal barrier dysfunction in cirrhosis is multifactorial, including alcohol, portal hypertension (vascular congestion and dysregulation), endotoxemia, SIBO, local inflammation and, most likely, immunological factors and medications. Key Messages This review summarizes major achievements regarding intestinal dysfunction in cirrhosis for future gastroenterology research. The question of whether this intestinal barrier dysfunction is accompanied and/or at least partly caused by structural and functional changes in the epithelial tight junction proteins is as yet unsolved. Development of new strategies to modulate gut-liver interaction is urgently needed.
Collapse
Affiliation(s)
- Hiroshi Fukui
- Department of Gastroenterology, Endocrinology and Metabolism, Nara Medical University, Kashihara, Japan
| | - Reiner Wiest
- Department of Gastroenterology, University Hospital of Visceral Surgery and Medicine, Bern, Switzerland
| |
Collapse
|
49
|
Fukui H, Wiest R. Changes of Intestinal Functions in Liver Cirrhosis. Inflamm Intest Dis 2016; 1:24-40. [PMID: 29922655 PMCID: PMC5988129 DOI: 10.1159/000444436] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 02/04/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Understanding of the gut-liver axis is important for the up-to-date management of liver cirrhosis, and changes of intestinal functions form the core of this interesting research field. SUMMARY Most investigators noted small intestinal dysmotility in their patients with liver cirrhosis. Marked changes in the contraction pattern were observed in early manometric studies. The orocecal transit time, particularly small intestinal transit, has generally been reported to be prolonged, which has been demonstrated in multiple investigations to be related to the severity of the liver disease (e.g., Child-Pugh class), the presence of small intestinal bacterial overgrowth (SIBO) and hepatic encephalopathy (HE) as well as a history of spontaneous bacterial peritonitis. Bacteriologically proven SIBO in proximal jejunal aspiration has been reported to be present in up to 59% of cirrhotic patients and is associated with systemic endotoxemia. Clinical and experimental studies suggest that delayed small bowel transit in liver cirrhosis may lead to SIBO, which could contribute to the symptoms of abdominal pain and diarrhea. In addition to autonomic neuropathy, metabolic derangements and diabetic state, SIBO itself may delay intestinal transit in cirrhotic patients. Several studies, both from the West and the East, have shown that the gut microbiota is altered in cirrhotic patients and particularly those with HE. Further, a quantitative change in Bacteroides/Firmicutes ratio, with a prevalence of potentially pathogenic bacteria (e.g., Enterobacteriaceae) and reduction in specific commensals (e.g., Lachnospiraceae), has been described. Structural and functional changes in the intestinal mucosa that contribute to increases in intestinal permeability for bacteria and their products have been observed in patients with liver cirrhosis, which is considered as an important pathogenetic factor for several complications. The mechanism of intestinal barrier dysfunction in cirrhosis is multifactorial, including alcohol, portal hypertension (vascular congestion and dysregulation), endotoxemia, SIBO, local inflammation and, most likely, immunological factors and medications. KEY MESSAGES This review summarizes major achievements regarding intestinal dysfunction in cirrhosis for future gastroenterology research. The question of whether this intestinal barrier dysfunction is accompanied and/or at least partly caused by structural and functional changes in the epithelial tight junction proteins is as yet unsolved. Development of new strategies to modulate gut-liver interaction is urgently needed.
Collapse
Affiliation(s)
- Hiroshi Fukui
- Department of Gastroenterology, Endocrinology and Metabolism, Nara Medical University, Kashihara, Japan
| | - Reiner Wiest
- Department of Gastroenterology, University Hospital of Visceral Surgery and Medicine, Bern, Switzerland
| |
Collapse
|
50
|
Abstract
Background Understanding of the gut-liver axis is important for the up-to-date management of liver cirrhosis, and changes of intestinal functions form the core of this interesting research field. Summary Most investigators noted small intestinal dysmotility in their patients with liver cirrhosis. Marked changes in the contraction pattern were observed in early manometric studies. The orocecal transit time, particularly small intestinal transit, has generally been reported to be prolonged, which has been demonstrated in multiple investigations to be related to the severity of the liver disease (e.g., Child-Pugh class), the presence of small intestinal bacterial overgrowth (SIBO) and hepatic encephalopathy (HE) as well as a history of spontaneous bacterial peritonitis. Bacteriologically proven SIBO in proximal jejunal aspiration has been reported to be present in up to 59% of cirrhotic patients and is associated with systemic endotoxemia. Clinical and experimental studies suggest that delayed small bowel transit in liver cirrhosis may lead to SIBO, which could contribute to the symptoms of abdominal pain and diarrhea. In addition to autonomic neuropathy, metabolic derangements and diabetic state, SIBO itself may delay intestinal transit in cirrhotic patients. Several studies, both from the West and the East, have shown that the gut microbiota is altered in cirrhotic patients and particularly those with HE. Further, a quantitative change in Bacteroides/Firmicutes ratio, with a prevalence of potentially pathogenic bacteria (e.g., Enterobacteriaceae) and reduction in specific commensals (e.g., Lachnospiraceae), has been described. Structural and functional changes in the intestinal mucosa that contribute to increases in intestinal permeability for bacteria and their products have been observed in patients with liver cirrhosis, which is considered as an important pathogenetic factor for several complications. The mechanism of intestinal barrier dysfunction in cirrhosis is multifactorial, including alcohol, portal hypertension (vascular congestion and dysregulation), endotoxemia, SIBO, local inflammation and, most likely, immunological factors and medications. Key Messages This review summarizes major achievements regarding intestinal dysfunction in cirrhosis for future gastroenterology research. The question of whether this intestinal barrier dysfunction is accompanied and/or at least partly caused by structural and functional changes in the epithelial tight junction proteins is as yet unsolved. Development of new strategies to modulate gut-liver interaction is urgently needed.
Collapse
Affiliation(s)
- Hiroshi Fukui
- Department of Gastroenterology, Endocrinology and Metabolism, Nara Medical University, Kashihara, Japan
| | - Reiner Wiest
- Department of Gastroenterology, University Hospital of Visceral Surgery and Medicine, Bern, Switzerland
| |
Collapse
|