Malnutrition is not related to alterations in energy balance in patients with stable liver cirrhosis

Nutritional status in patients with chronic pancreatitis and liver cirrhosis is related to disease conditions and not dietary habits

Malnutrition is a common complication of chronic pancreatitis (CP) and liver cirrhosis (LC). Inadequate food intake is considered a relevant driver of malnutrition in both entities. However, the contribution of habitual diet to impaired nutritional status is unclear. In a prospective, multicenter cross-sectional study, we recruited patients with confirmed CP or LC and healthy volunteers as a control group. Malnutrition was diagnosed according to the Global Leadership Initiative on Malnutrition criteria. We comprehensively investigated habitual dietary intake on nutrient, food group, and dietary pattern level applying two validated food frequency questionnaires. We included 144 patients (CP: n = 66; LC: n = 78) and 94 control subjects. Malnutrition was prevalent in 64% and 62% of patients with CP or LC, respectively. In both CP and LC, despite slightly altered food group consumption in malnourished and non-malnourished patients there were no differences in energy or nutrient intake as well as dietary quality. Compared to controls patients showed distinct dietary food group habits. Patients consumed less alcohol but also lower quantities of fruits and vegetables as well as whole grain products (p < 0.001, respectively). Nevertheless, overall dietary quality was comparable between patients and healthy controls. Nutritional status in CP and LC patients is rather related to disease than habitual dietary intake supporting the relevance of other etiologic factors for malnutrition such as malassimilation or chronic inflammation. Despite distinct disease-related differences, overall dietary quality in patients with CP or LC was comparable to healthy subjects, which suggests susceptibility to dietary counselling and the benefits of nutrition therapy in these entities.

Assessment of resting energy expenditure in patients with cirrhosis

BACKGROUND

Malnutrition affects 20% to 50% of patients with cirrhosis. It may be associated with serious complications and has a direct impact on prognosis. Resting energy expenditure (REE) is an important parameter to guide the optimization of therapy and recovery of nutritional status in patients with cirrhosis. However, the REE of patients with cirrhosis is still unclear, casting doubt upon the optimal nutritional management approach.

AIM

To identify the best method that predicts the REE of cirrhotic patients, using indirect calorimetry (IC) as the gold standard.

METHODS

An observational study was performed on 90 patients with cirrhosis. REE was assessed by IC, bioelectrical impedance analysis (BIA), and predictive formulas, which were compared using Bland-Altman plots and the Student’s t-test.

RESULTS

REE values measured by IC (1607.72 ± 257.4 kcal) differed significantly from those determined by all other methods (BIA: 1790.48 ± 352.1 kcal; Harris & Benedict equation: 2373.54 ± 254.9 kcal; IOM equation: 1648.95 ± 185.6 kcal; Cunningham equation: 1764.29 ± 246.2 kcal), except the Food and Agriculture Organization of the United Nations, World Health Organization, and United Nations University (FAO/WHO/UNU) (1616.07 ± 214.6 kcal) and McArdle (1611.30 ± 241.8 kcal) equations. We found no significant association when comparing IC and 24-h dietary recall among different Child-Pugh classes of cirrhosis.

CONCLUSION

The IOM and FAO/WHO/UNU equations have the best agreement with the CI. These results indicate a possibility of different tools for the clinical practice on cirrhotic patients.

Resting energy expenditure in cirrhotic patients with and without hepatocellular carcinoma

BACKGROUND

The diagnosis of malnutrition in patients with independent hepatocellular carcinoma (HCC) varies from 20% to 50%, is related to important complications and has a direct impact on the prognosis. Determination of the resting energy expenditure (REE) has become an important parameter in this population, as it allows therapeutic adjustments to recover their nutritional status. The REE in cirrhosis, with and without HCC, is not clearly defined, and requires the identification and definition of the best nutritional approach.

AIM

To evaluate the REE of patients with cirrhosis, with and without HCC.

METHODS

This is a prospective observational study evaluating the REE of 118 patients, 33 with cirrhosis and hepatocellular carcinoma and a control group of 85 patients with cirrhosis without HCC, using indirect calorimetry (IC), bioimpedance, and predictive formulas.

RESULTS

The REE determined by IC in cirrhotic patients with HCC was 1643 ± 364 and in those without HCC was 1526 ± 277 (P = 0.064). The REE value as assessed by bioimpedance was 1529 ± 501 for those with HCC and 1660 ± 385 for those without HCC (P = 0.136). When comparing the values of REE determined by IC and predictive formulas in cirrhotics with HCC, it was observed that only the formulas of the Food and Agriculture Organization (FAO)/World Health Organization (WHO) (1985) and Cunningham (1980) presented values similar to those determined by IC. When comparing the REE values determined by IC and predictive formulas in cirrhotics without HCC, it was observed that the formulas of Schofield (1985), FAO/WHO (1985), WHO (2000), Institute of Medicine (IOM) (2005) and Katch and McArdie (1996) presented values similar to those determined by IC.

CONCLUSION

The FAO/WHO formula (1985) could be used for cirrhotic patients with or without HCC; as it is the one with the values closest to those obtained by IC in these cirrhotic patients.

Pre-sarcopenia determines post-progression outcomes in advanced hepatocellular carcinoma after sorafenib failure

Many second-line therapies are recently approved for patients with advanced hepatocellular carcinoma (HCC), in whom protein malnutrition is prevalent that would affect treatment outcomes. In this study, we aimed to investigate the role of pre-sarcopenia and muscle restoration in patients with sorafenib-failed advanced HCC. From August 2012 to March 2017, 385 patients who developed radiology-proven HCC progression after sorafenib treatment were enrolled in the study. Pre-sarcopenia is defined as transverse psoas muscle thickness per body height < 16.8 mm/m, which was prevalent (64.7%) in our patients. Age > 60 years, female gender, and body mass index < 22 kg/m² were independent predictors to the development of pre-sarcopenia. Patients with muscle depletion had significantly worse post-progression survival (PPS) compared with their counterparts (median PPS: 3.8 vs. 5.8 months, p = 0.003), particularly in those with intermediate liver reserves (Child–Pugh class B or Albumin-bilirubin grade 2). Besides, pre-sarcopenia independently predicted post-progression mortality in sorafenib-failed HCC (hazard ratio: 1.340, p = 0.012). In patients who developed pre-sarcopenia before sorafenib treatment, muscle restoration was associated with a longer PPS compared with their counterparts (6.3 vs. 3.6 months, p = 0.043). In conclusion, pre-sarcopenia independently determined the outcomes of sorafenib-failed HCC. Nutrition support to restore muscle mass would prolong survival for higher-risk patients.

Utility of the simplified measurements of muscle mass in patients with gastrointestinal and chronic liver diseases

Sarcopenia is an important prognostic factor in patients with gastrointestinal and chronic liver diseases. Computed tomography and bioelectrical impedance analysis are the gold standards for measuring skeletal muscle mass for the diagnosis of decreased muscle mass, but there are some institutions where BIA and CT cannot be carried out. We evaluated the utility of simplified methods for measuring muscle mass; the psoas muscle mass index (PMI) method, simple PMI method, and arm muscle area (AMA) method. This retrospective study included 331 patients with gastrointestinal diseases and 81 patients with chronic liver diseases who were admitted from June 2018 to December 2019 at Municipal Hospital of Kofu. The skeletal muscle mass was measured using the PMI via the volume analyzer SYNAPSE VINCENT ver3.0, simple PMI based on CT imaging, and AMA method. Positive correlations were found between muscle mass measured by PMI and simple PMI, PMI and AMA, and simple PMI and AMA in patients with gastrointestinal diseases (correlation coefficients = 0.76, 0.57, 0.47, respectively, p < 0.001). Positive correlations were observed between muscle mass measured by PMI and simple PMI, PMI and AMA, and simple PMI and AMA in chronic liver diseases (correlation coefficients = 0.77, 0.53, 0.45, respectively, p < 0.001). Measurement of muscle mass by the AMA method showed some correlation with the PMI method. Measurement of muscle mass by the simple PMI method showed correlation with the PMI method. These simplified methods can be alternative methods of evaluating muscle mass in patients with gastrointestinal and chronic liver disease.

Semiautomatic software for measurement of abdominal muscle and adipose areas using computed tomography: A STROBE-compliant article

The aim of the study was to introduce our in-house software to measure the muscle and adipose area on axial computed tomography (CT) scans and to compare with various quantification methods.Our institutional review board approved this retrospective study and informed consent was waived. We developed in-house software to identify body composition analysis on CT scan, which semiautomatically operates 3 image processing steps. Abdominal images were obtained using multidetector row CT (MDCT). Two radiologists analyzed the same cross-sectional areas of subcutaneous fat, muscle, and visceral fat using the following techniques: manual measurements, Aquarius, ImageJ, and our newly developed software. We calculated an intraclass correlation coefficient (ICC) for comparison of muscle and fat areas quantified by various measurement methods using a 2-way random model. Interobserver agreement between the radiologists was also evaluated.Agreements in the measurement of subcutaneous fat and muscle areas were excellent among the methods (ICC = 0.962 and 0.897, respectively), and that of the visceral fat area was good (ICC = 0.822). In the subgroup analysis, ICC of the visceral fat area in the female group and in subjects with ascites was slightly lower than the other group (ICC = 0.742 and 0.787, respectively). The correlation coefficients between our software and other methods were relatively high (r = 0.854-0.996). Additionally, ICCs between both observers of our program for quantification of subcutaneous fat, muscle, and visceral fat areas were 0.999, 0.980, and 0.999, respectively.In conclusion, our method showed be reliable in quantifying muscle and adipose tissue using cross-sectional areas of MDCT with high reproducibility.

Skeletal muscle mass depletion in patients with hepatitis C virus infection

OBJECTIVE

The aim was to assess the relationship between muscle mass depletion and chronic hepatitis C virus (HCV) infection.

PATIENTS AND METHODS

We retrospectively evaluated abdominal computed tomography data for 611 patients. The participants included 302 patients with HCV infection and 309 patients with gallstones (as a control). The skeletal muscle mass at the level of the third lumber vertebra (L3) was measured from the computed tomography images and normalized for height to calculate the L3 skeletal muscle index (L3-SMI, cm/m). Statistical analysis was carried out separately for each sex, given that L3-SMI differs significantly between men and women.

RESULTS

L3-SMI showed no significant difference between chronic hepatitis patients and gallstone patients in either sex. L3-SMI was significantly lower in male cirrhotic patients than in those with chronic hepatitis (P<0.001). The Child-Pugh score was correlated negatively with L3-SMI in male patients with HCV-related cirrhosis (ρ=0.200, P=0.031). In addition, the BMI in both sexes was associated with L3-SMI in the gallstone and chronic hepatitis group, in the chronic hepatitis and liver cirrhosis group, and in the liver cirrhosis group.

CONCLUSION

Skeletal muscle mass is not affected by chronic HCV infection in patients without cirrhosis and decreases in accordance with liver disease progression in male patients with chronic HCV infection.

EASL Clinical Practice Guidelines on nutrition in chronic liver disease

A frequent complication in liver cirrhosis is malnutrition, which is associated with the progression of liver failure, and with a higher rate of complications including infections, hepatic encephalopathy and ascites. In recent years, the rising prevalence of obesity has led to an increase in the number of cirrhosis cases related to non-alcoholic steatohepatitis. Malnutrition, obesity and sarcopenic obesity may worsen the prognosis of patients with liver cirrhosis and lower their survival. Nutritional monitoring and intervention is therefore crucial in chronic liver disease. These Clinical Practice Guidelines review the present knowledge in the field of nutrition in chronic liver disease and promote further research on this topic. Screening, assessment and principles of nutritional management are examined, with recommendations provided in specific settings such as hepatic encephalopathy, cirrhotic patients with bone disease, patients undergoing liver surgery or transplantation and critically ill cirrhotic patients.

Preoperative optimization for major hepatic resection

PURPOSE

Major hepatic resections are performed for primary hepatobiliary malignancies, metastatic disease, and benign lesions. Patients with chronic liver disease, including cirrhosis and steatosis, are at an elevated risk of malnutrition and impaired strength and exercise capacity, deficits which cause increased risk of postoperative complications and mortality. The aims of this report are to discuss the pathophysiology of changes in nutrition, exercise capacity, and muscle strength in patient populations likely to require major hepatectomy, and review recommendations for preoperative evaluation and optimization.

METHODS

Nutritional and functional impairment in preoperative hepatectomy patients, especially those with underlying liver disease, have a complex and multifactorial physiologic basis that is not completely understood.

RESULTS

Recognition of malnutrition and compromised strength and exercise tolerance preoperatively can be difficult, but is critical in providing the opportunity to intervene prior to major hepatic resection and potentially improve postoperative outcomes. There is promising data on a variety of nutritional strategies to ensure adequate intake of calories, proteins, vitamins, and minerals in patients with cirrhosis and reduce liver size and degree of fatty infiltration in patients with hepatic steatosis. Emerging evidence supports structured exercise programs to improve exercise tolerance and counteract muscle wasting.

CONCLUSIONS

The importance of nutrition and functional status in patients indicated for major liver resection is apparent, and emerging evidence supports structured preoperative preparation programs involving nutritional intervention and exercise training. Further research is needed in this field to develop optimal protocols to evaluate and treat this heterogeneous cohort of patients.

Sarcopenia Impairs Prognosis of Patients with Hepatocellular Carcinoma: The Role of Liver Functional Reserve and Tumor-Related Factors in Loss of Skeletal Muscle Volume

Sarcopenia impairs survival in patients with hepatocellular carcinoma (HCC). This study aimed to clarify the factors that contribute to decreased skeletal muscle volume in patients with HCC. The third lumbar vertebra skeletal muscle index (L3 SMI) in 351 consecutive patients with HCC was calculated to identify sarcopenia. Sarcopenia was defined as an L3 SMI value ≤ 29.0 cm²/m² for women and ≤ 36.0 cm²/m² for men. The factors affecting L3 SMI were analyzed by multiple linear regression analysis and tree-based models. Of the 351 HCC patients, 33 were diagnosed as having sarcopenia and showed poor prognosis compared with non-sarcopenia patients (p = 0.007). However, this significant difference disappeared after the adjustments for age, sex, Child–Pugh score, maximum tumor size, tumor number, and the degree of portal vein invasion by propensity score matching analysis. Multiple linear regression analysis showed that age (p = 0.015) and sex (p < 0.0001) were significantly correlated with a decrease in L3 SMI. Tree-based models revealed that sex (female) is the most significant factor that affects L3 SMI. In male patients, L3 SMI was decreased by aging, increased Child–Pugh score (≥56 years), and enlarged tumor size (<56 years). Maintaining liver functional reserve and early diagnosis and therapy for HCC are vital to prevent skeletal muscle depletion and improve the prognosis of patients with HCC.

Factors related to increased resting energy expenditure in men with liver cirrhosis

OBJECTIVE

Hypermetabolism in cirrhosis is associated with a high risk of complications and mortality. However, studies about underlying mechanisms are usually focussed on isolated potential determinants and specific etiologies, with contradictory results. We aimed at investigating differences in nutrition, metabolic hormones, and hepatic function between hypermetabolic and nonhypermetabolic men with cirrhosis of the liver.

PATIENTS AND METHODS

We prospectively enrolled 48 male cirrhotic inpatients. We evaluated their resting energy expenditure (REE) and substrate utilization by indirect calorimetry, body composition by dual-energy X-ray absorptiometry, liver function, and levels of major hormones involved in energy metabolism by serum sample tests. Patients with ascites, specific metabolic disturbances, and hepatocellular carcinoma were excluded.

RESULTS

REE and REE adjusted per fat-free mass (FFM) were significantly increased in cirrhotic patients. Overall, 58.3% of cirrhotic patients were classified as hypermetabolic. Groups did not differ significantly in age, etiology of cirrhosis, liver function, presence of ascites, use of diuretics, β-blockers, or presence of transjugular intrahepatic portosystemic shunts. Hypermetabolic cirrhotic patients had lower weight, BMI (P<0.05), nonprotein respiratory quotient (P<0.01), leptin (P<0.05), and leptin adjusted per fat mass (FM) (P<0.05), but higher FFM% (P<0.05) and insulin resistance [homeostatic model assessment-insulin resistance (HOMA-IR)] (P<0.05). Only HOMA-IR, leptin/FM, and FFM% were independently related to the presence of hypermetabolism.

CONCLUSION

Hypermetabolic cirrhotic men are characterized by lower weight, higher FFM%, insulin resistance, and lower leptin/FM when compared with nonhypermetabolic men. HOMA-IR, FFM%, and leptin/FM were independently associated with hypermetabolism, and may serve as easily detectable markers of this condition in daily clinical practice.

Sarcopenia is an independent prognostic factor in male patients with diffuse large B-cell lymphoma

Sarcopenia reportedly predicts poor outcomes in elderly patients with diffuse large B-cell lymphoma (DLBCL). However, because previous studies only involved elderly patients, it is difficult to generalize these results to all patients with DLBCL. We retrospectively analyzed 207 patients with DLBCL who received the R-CHOP or R-THP-COP regimen between June 2004 and May 2014. Sarcopenia was measured by the analysis of CT images at the L3 level before treatment. The surface of muscular tissues was selected according to the CT Hounsfield unit. This value was normalized for stature in order to calculate the L3 skeletal muscle index (L3 SMI, cm(2)/m(2)). Median age at diagnosis in the 121 males and 86 females was 67 years (range, 19-86 years). The sex-specific cutoffs for the L3 SMI were determined by receiver operator curve (ROC) analysis. Sarcopenic patients were older than non-sarcopenic patients, with a median age of 70 and 65 years, respectively (p < 0.001). Other International Prognostic Index factors were not significantly different when comparing sarcopenic and non-sarcopenic patients. With a median follow-up of 50.4 months, the 3-year overall survival (OS) was 70 % in the sarcopenic group and 85 % in the non-sarcopenic group (p = 0.0260). In a subgroup analysis by gender, there was a significant difference in the OS when comparing sarcopenic and non-sarcopenic patients in males but not in females (p = 0.0003, p = 0.4440, respectively). Sarcopenia is an independent prognostic factor in male patients with DLBCL.

Sarcopenia impairs prognosis of patients with liver cirrhosis

OBJECTIVE

Sarcopenia is characterized by the loss of skeletal muscle mass, and is reported to appear in patients with liver cirrhosis (LC). The aim of this study was to investigate the prevalence of sarcopenia in patients with LC, and to test the association between sarcopenia and patient outcomes. We also analyzed the effect of branched-chain amino acid (BCAA) supplementation on sarcopenic LC.

METHODS

Clinical and blood biochemical data of 130 patients with LC who underwent abdominal computed tomography scan were analyzed in this retrospective study. The cross-sectional area of skeletal muscles was measured at the level of the third lumbar vertebra on the scan. The skeletal muscle index was calculated to identify sarcopenia. Cirrhotic patients who were treated with BCAA supplementation of 12 g/d for ≥ 1 y were defined as the BCAA group, and the effect of BCAA on sarcopenic LC was evaluated.

RESULTS

Sixty-eight percent of all patients (82% of men and 50% of women) were diagnosed with sarcopenia. Male sex (P = 0.01) and body mass index (P < 0.0001) were predictors of sarcopenia. The multivariate Cox proportional hazards model found BCAA supplementation (hazard ratio [HR], 0.38; P = 0.01), sarcopenia (HR, 3.03; P < 0.01), and Child-Pugh classes B (HR, 2.39; P = 0.03) and C (HR, 5.49; P < 0.001) to be independently associated with mortality. The mortality of sarcopenic LC was significantly higher than that of non-sarcopenic LC (P = 0.01). Moreover, BCAA supplementation improved the survival of sarcopenic patients in subgroup analysis (P < 0.01).

CONCLUSIONS

Sarcopenia is significantly associated with mortality in patients with LC. BCAA supplementation might be associated with improved survival of such patients.

Negative energy balance secondary to inadequate dietary intake of patients on the waiting list for liver transplantation

OBJECTIVES

The aim of this study was to evaluate the energy balance (EB) of patients on the waiting list for liver transplantation, using total energy expenditure (TEE) assessment and total caloric intake (TCI).

METHODS

We analyzed nutrient adequacy and factors associated with it. EB was obtained by subtracting the TCI (obtained by 3-d food record) from TEE, which was measured as resting energy expenditure and physical activity factor calculation. Socioeconomic and clinical data also were evaluated. Univariate and multiple linear regressions were used (P < 0.05). Seventy-three patients were included.

RESULTS

The TEE was 2318.5 kcal, and the TCI was 1485.1 kcal, with 81.6% of patients presenting with negative EB. There was no significant association between TCI and socioeconomic variables, medications, and encephalopathy (P > 0.05). Women, less-educated patients, those with ascites, and those who were malnourished presented with lower TCI (P < 0.05). Severity of disease, by Child-Pugh and Model for End-Stage Liver Disease scores were associated with EB (P < 0.05). Child-Pugh remained significant after multivariate analyses. Energy inadequacy was observed in 91.8% of patients, and protein inadequacy in 72.6% of patients. Polyunsaturated fatty acid (64.4%) and monounsaturated fatty acid (91.8%) and fiber (94.5%) inadequacies also were high. The percentage of adequate intake was less than 10% for vitamins B5 and D, calcium, folic acid, and potassium, and higher percentages of adequate intake (>80%) were found for iron and vitamins B1 and B12. Moreover, 54.8% and 16.4% of the patients had excessive sodium and cholesterol intakes, respectively.

CONCLUSION

Negative EB was highly prevalent among patients on the waiting list for liver transplantation, and was associated with the severity of liver disease. Negative EB was primarily affected by low food intake. The food intake data were characterized by low overall energy and protein intake and inadequate composition of the patient's diet plan, which tended to be characterized by specific nutrient deficiencies and excesses.

Hyper- and hypometabolism are not related to nutritional status of patients on the waiting list for liver transplantation

BACKGROUND & AIMS

Metabolic disorders and malnutrition are well known conditions reported in patients with liver disease (LD), but the relationship between them are underexplored. So, the aim of this study was to assess the resting energy expenditure (REE) of these patients, identifying the prevalence of hyper- and hypometabolism. In addition, to evaluate whether malnutrition and clinical variables were associated with REE and metabolic disorders.

METHODS

The REE was measured by indirect calorimetry and predicted by the Harris and Benedict formula (REEHB). Nutritional status was assessed by different methods. The etiology, severity and complications of LD were also evaluated.

RESULTS

A total of 81 patients were assessed. The measured REE was 1587.5 ± 426.6 kcal. The REE was overestimated by the REEHB (REE:REEHB <0.8) in 7.4% and underestimated (REE:REEHB >1.2) in 24.7% of the patients. The REE was lower in malnourished patients (p < 0.05). However, hyper- and hypometabolism were not associated with nutritional status (p > 0.05). The REE and hypermetabolism were not associated with LD, but hypometabolic patients had a higher prevalence of Child C, and had higher values for MELD, INR and total bilirubin (p < 0.05). After multiple regression analyses, the REE was significantly associated (p < 0.05) with intracellular body water, arm muscle area and serum glucose. Serum glucose was only significantly associated (p < 0.05) with hypermetabolism, and INR with hypometabolism.

CONCLUSION

Changes in resting metabolism are present but not universal. The hypermetabolism was associated with extrahepatic factors, and hypometabolism with the severity of LD. Under these conditions in the clinical setting, calculated energy requirements using the HB formula should be adjusted.

Abnormalities in the serum phospholipids fatty acid profile in patients with alcoholic liver cirrhosis - a pilot study

The fatty acid composition of serum phospholipids were analyzed in 20 patients with alcoholic liver cirrhosis (11 with malnutrition and 9 with acceptable nutritional status); 25 healthy age and sex-matched adults were used as controls. Cirrhotic patients showed higher levels of palmitic acid and total saturated fatty acids than healthy subjects. Total n-6 and n-3 polyunsaturated fatty acids (PUFA), and levels of linoleic, dihomo-gama linolenic, arachidonic, and docosahexaenoic acid were significantly lower (p<0.001) in patients with alcoholic cirrhosis compared to healthy controls. Significant changes were also found between patients stratified according to nutritional status. In particular, the sum of n-3 PUFA was significantly lower (p<0.001) and ratio of n-6/n-3 fatty acids was higher (p<0.01) in malnourished patients when compared to the patients with acceptable nutritional status. Furthermore, important changes in the levels of saturated fatty acids, palmitoleic and oleic acid and long-chain PUFA were found in well-nourished patients with alcoholic cirrhosis as well. Our present data confirmed evidence that malnutrition is one of the factors that led to lower levels of polyunsaturated fatty acids in patients with alcoholic liver cirrhosis. PUFA supplementation in the latter needs further investigation.

Sarcopenia and a physiologically low respiratory quotient in patients with cirrhosis: a prospective controlled study

Patients with cirrhosis have increased gluconeogenesis and fatty acid oxidation that may contribute to a low respiratory quotient (RQ), and this may be linked to sarcopenia and metabolic decompensation when these patients are hospitalized. Therefore, we conducted a prospective study to measure RQ and its impact on skeletal muscle mass, survival, and related complications in hospitalized cirrhotic patients. Fasting RQ and resting energy expenditure (REE) were determined by indirect calorimetry in cirrhotic patients (n = 25), and age, sex, and weight-matched healthy controls (n = 25). Abdominal muscle area was quantified by computed tomography scanning. In cirrhotic patients we also examined the impact of RQ on mortality, repeat hospitalizations, and liver transplantation. Mean RQ in patients with cirrhosis (0.63 ± 0.05) was significantly lower (P < 0.0001) than healthy matched controls (0.84 ± 0.06). Psoas muscle area in cirrhosis (24.0 ± 6.6 cm(2)) was significantly (P < 0.001) lower than in controls (35.9 ± 9.5 cm(2)). RQ correlated with the reduction in psoas muscle area (r(2) = 0.41; P = 0.01). However, in patients with cirrhosis a reduced RQ did not predict short-term survival or risk of developing complications. When REE was normalized to psoas area, energy expenditure was significantly higher (P < 0.001) in patients with cirrhosis (66.7 ± 17.8 kcal/cm(2)) compared with controls (47.7 ± 7.9 kcal/cm(2)). We conclude that hospitalized patients with cirrhosis have RQs well below the traditional lowest physiological value of 0.69, and this metabolic state is accompanied by reduced skeletal muscle area. Although low RQ does not predict short-term mortality in these patients, it may reflect a decompensated metabolic state that requires careful nutritional management with appropriate consideration for preservation of skeletal muscle mass.

Severe muscle depletion in patients on the liver transplant wait list: its prevalence and independent prognostic value

As detected by cross-sectional imaging, severe muscle depletion, which is termed sarcopenia, holds promise for prognostication in patients with cirrhosis. Our aims were to describe the prevalence and predictors of sarcopenia in patients with cirrhosis listed for liver transplantation (LT) and to determine its independent prognostic significance for the prediction of waiting-list mortality. Adults listed for LT who underwent abdominal computed tomography/magnetic resonance imaging within 6 weeks of activation were retrospectively identified. The exclusions were hepatocellular carcinoma, acute liver failure, prior LT, and listing for multivisceral transplantation or living related LT. Sixty percent of the 142 eligible patients were male, the median age was 53 years, and the median Model for End-Stage Liver Disease (MELD) score at listing was 15. Forty-one percent were sarcopenic; sarcopenia was more prevalent in males versus females (54% versus 21%, P < 0.001) and increased with the Child-Pugh class (10% for class A, 34% for class B, and 54% for class C, P = 0.007). Male sex, the dry-weight body mass index (BMI), and Child-Pugh class C cirrhosis (but not the MELD score) were independent predictors of sarcopenia. Sarcopenia was an independent predictor of mortality (hazard ratio = 2.36, 95% confidence interval = 1.23-4.53) after adjustments for age and MELD scores. In conclusion, sarcopenia is associated with increased waiting-list mortality and is poorly predicted by subjective nutritional assessment tools such as BMI and subjective global assessment. If this is validated in larger studies, the objective assessment of sarcopenia holds promise for prognostication in this patient population.

Guidelines on nutritional management in Japanese patients with liver cirrhosis from the perspective of preventing hepatocellular carcinoma

AIM

  The Japanese Nutritional Study Group for Liver Cirrhosis (JNUS) was assembled in 2008 with the support of a Health Labor Sciences Research Grant from the Ministry of Health, Labor and Welfare of Japan. The goal of the study group was to propose new nutritional guidelines for Japanese patients with liver cirrhosis (LC), with the aim of preventing hepatocellular carcinoma.

METHODS

  Between 2008 and 2010, the member investigators of JNUS conducted various clinical and experimental studies on nutrition on LC. These included anthropometric studies, a questionnaire study on daily nutrient intake, clinical trials, experimental studies using animal models, re-evaluation of previous publications and patient education. Over this 3-year period, the group members regularly discussed the nutritional issues related to LC, and a proposal was finally produced.

RESULTS

  Based on the results of JNUS projects and discussions among the members, general recommendations were made on how Japanese patients with LC should be managed nutritionally. These recommendations were proposed with a specific regard to the prevention of hepatocarcinogenesis.

CONCLUSION

  The new JNUS guidelines on nutritional management for Japanese patients with LC will be useful for the actual nutritional management of patients with LC. The JNUS members hope that these guidelines will form the basis for future discussions and provide some direction in nutritional studies in the field of hepatology.

Molecular mechanisms of cachexia in chronic disease

Cachexia is a metabolic syndrome that manifests with excessive weight loss and disproportionate muscle wasting. It is related to many different chronic diseases, such as cancer, infections, liver disease, inflammatory bowel disease, cardiac disease, chronic obstructive pulmonary disease, chronic renal failure and rheumatoid arthritis. Cachexia is linked with poor outcome for the patients. In this article, we explore the role of the hypothalamus, liver, muscle tissue and adipose tissue in the pathogenesis of this syndrome, particularly concentrating on the role of cytokines, hormones and cell energy-controlling pathways (such as AMPK, PI3K/Akt and mTOR). We also look at possible future directions for therapeutic strategies.

Analysis of energy utilization and body composition in kidney, bladder, and adrenal cancer patients

OBJECTIVE

To investigate resting energy expenditure (REE) and body composition and the relationship between substrate utilization and energy expenditure in urologic cancer patients.

PATIENTS AND METHODS

Measured resting energy expenditure (mREE) was detected by indirect calorimetry in 122 urologic cancer patients and 131 control subjects. Extracellular fluid (ECF), intracellular fluid (ICF), and total water (TW) were measured by bioelectrical impedance appliance. Fat oxidation rate (F-O), carbohydrate oxidation rate, fat mass (FM), and fat free mass (FFM) were further determined.

RESULTS

Compared with the controls, cancer patients showed significantly elevated mREE and mREE/FFM (P = 0.049; P < 0.001). Of all the cancer patients, 50% (n = 61) were hypermetabolic, 43.4% (n = 53) normometabolic, and 6.6% (n = 8) hypometabolic, whereas 35.1% (n = 46) of the controls were hypermetabolic, 56.5% (n = 74) normometabolic, and 8.4% (n = 11) hypometabolic. REE was correlated to substrate oxidation rate (R(2) = 0.710). Cancer patients exhibited no significant difference in FM, FM/body weight (BW) and FFM, compared with controls. Cancer patients presented no significant difference in TW compared with controls (P = 0.791), but they had increased ECF (P < 0.001) and decreased ICF (P < 0.001).

CONCLUSION

Aberrations in substrate utilization may contribute to the elevated energy expenditure in urologic cancer patients. Cancer type and pathologic stage are influential factors of REE.

Factors associated with nutritional status in liver transplant patients who survived the first year after transplantation

BACKGROUND AND AIMS

Most studies published focus on the evaluation of the impact of nutritional status on the morbidity and mortality during the immediate postoperative period or on the short-term evolution of liver transplant patients. The aim of the study was to evaluate long-term trends in nutritional status.

METHODS

Seventy patients consecutively submitted to liver transplantation were studied. Nutritional assessment was performed the day before transplantation and the 45, 90, 180 and 365 days after transplantation, consisting of determination of dietary intake, anthropometric and biochemical analysis.

RESULTS

Sixty-nine percent of the patients presented with malnutrition on the day before liver transplantation, decreasing to 44% at end of the first year. The prevalence of protein-calorie malnutrition (PCM) was 63% at 90 days post-transplant. A significant difference of PCM was observed between patients with cirrhosis and non-cirrhotic disease (53.6% x 100%) at 90 days post-transplant. The pre-transplant nutritional diagnosis and 90-day calorie intake were identified as variables independently associated with nutritional status at 90 days post-transplant. The variables independently associated with nutritional status in the 1-year assessment were pre-transplant PCM and 365-day calorie requirements.

CONCLUSION

No influence on nutritional status was observed for peri- or postoperative factors after 3 or 12 months of follow up. As expected, dietary factors, especially adequate calorie intake, were always associated with nutritional status during all periods analyzed.

Nutritional treatment of chronic liver failure

The liver plays a central role in the regulation of nutrition by trafficking the metabolism of nutrients, their distribution and appropriate use. Accordingly, protein-energy malnutrition is common in patients with advanced liver disease, and it is a significant prognostic factor, affecting survival, the success of liver transplantation and quality of life. Clinical guidelines for the assessment and treatment of malnutrition have been issued by International societies, suggesting that nutritional therapy should be instituted in all patients where requirements are not adequately met by diet. The supplementation of the diet with amino acids (mainly branched-chain amino acids) and trace elements may improve nutritional status, liver function and hepatic encephalopathy. Nutritional issues should be carefully considered in Liver Units treating patients with advanced cirrhosis, and long-term, carefully controlled studies are needed to better define the type of nutritional support and the amount and timing of administration.

Role of nutrition in liver transplantation for end-stage chronic liver disease

Patients with end-stage liver disease often reveal significant protein-energy malnutrition, which may deteriorate after listing for transplantation. Since malnutrition affects post-transplant survival, precise assessment must be an integral part of pre- and post-surgical management. While there is wide agreement that aggressive treatment of nutritional deficiencies is required, strong scientific evidence supporting nutritional therapy is sparse. In practice, oral nutritional supplements are preferred over parenteral nutrition, but enteral tube feeding may be necessary to maintain adequate calorie intake. Protein restriction should be avoided and administration of branched-chain amino acids may help yield a sufficient protein supply. Specific problems such as micronutrient deficiency, fluid balance, cholestasis, encephalopathy, and comorbid conditions need attention in order to optimize patient outcome.

Evaluation of nutritional status of nonhospitalized patients with liver cirrhosis

BACKGROUND

[corrected] Protein-calorie malnutrition is a frequent finding in patients with chronic liver disease, but investigations of nutritional status have been rarely performed in individuals seen at outpatient clinics

AIM

To evaluate the nutritional status of patients with alcoholic and nonalcoholic cirrhosis, attended for the first time at a reference outpatient clinic for liver diseases.

PATIENTS AND METHODS

A total of 300 consecutive patients attended at the outpatient clinics of a reference center for liver diseases were investigated. Anthropometric evaluation was performed by the usual parameters: triceps skinfold, arm circumference and arm muscle circumference. Biochemical parameters included creatinine/height index, serum albumin and lymphocytes count. The nutritional diagnosis was based on the PCM score proposed by Mendenhall et al. Food intake was retrospectively evaluated using 24-hour dietary recall data.

RESULTS

About 71% of the patients studied were chronic alcohol abusers, whereas in 29% cirrhosis was of nonalcoholic etiology. Independently of the disease etiology 75.3% of the patients showed some degree of protein-calorie malnutrition, which was moderate or severe in 38.3% of them. More advanced protein-calorie malnutrition degrees were associated with lower energy and protein intake. The prevalence of moderate or severe protein-calorie malnutrition was higher in patients classified as Child-Pugh C than in patients classified as Child-Pugh A (21% x 58%, respectively). Regarding sexual differences, fat reserves, evaluated by triceps skinfold, were more depleted in females than in males (48.6% x 26.6%) regardless of the etiology of the cirrhosis, whereas muscle reserves (arm muscle circumference) were more depleted in males (43.4% x 13.4%) regardless of the etiology of cirrhosis. In contrast, cirrhosis of alcoholic etiology was determinant in reducing arm muscle circumference in females (20% x 9.1%)

CONCLUSIONS

These data highlight the high prevalence of protein-calorie malnutrition occurring early in the natural history of the disease and accompanying functional hepatic deterioration. In addition, attention should be paid to the different gender patterns of response to protein-calorie malnutrition in these patients.

Body composition, muscle function, and energy expenditure in patients with liver cirrhosis: a comprehensive study

BACKGROUND

Data describing the nutritional status of patients with liver cirrhosis of diverse origin, as assessed by direct body-composition methods, are limited.

OBJECTIVE

We sought to provide a comprehensive assessment of nutritional status and metabolic activity in patients with liver cirrhosis by using the most accurate direct methods available.

DESIGN

Two hundred sixty-eight patients (179 M, 89 F; x +/- SEM age: 50.1 +/- 0.6 y) with liver cirrhosis underwent measurements of total body protein by neutron activation analysis, of total body fat and bone mineral by dual-energy X-ray absorptiometry, of resting energy expenditure by indirect calorimetry, of grip strength by dynamometry, and of respiratory muscle strength by using a pressure transducer. Dietary intakes of energy and protein were assessed and indexed to resting energy expenditure and energy intake, respectively.

RESULTS

Significant protein depletion, seen in 51% of patients, was significantly (P<0.0001) more prevalent in men (63%) than in women (28%). This sex difference occurred irrespective of disease severity or origin. The prevalence of protein depletion increased significantly (P<0.0001) with disease severity. Protein depletion was associated with decreased muscle function but not with lower energy and protein intake. Energy intake was significantly (P=0.002) higher in men than in women, whereas protein intakes did not differ significantly (P=0.12). Hypermetabolism, seen in 15% of patients, was not associated with sex, origin or severity of disease, protein depletion, ascites, or presence of tumor.

CONCLUSIONS

Poor nutritional status with protein depletion and reduced muscle function was a common finding, particularly in men, and was not related to the presence of hypermetabolism or reduced energy and protein intakes. The greater conservation of protein stores in women than in men warrants further investigation.

The levels of ghrelin, leptin, TNF-alpha, and IL-6 in liver cirrhosis and hepatocellular carcinoma due to HBV and HDV infection

Background/Aim. Malnutrition, a common problem in liver cirrhosis and HCC, may readily deteriorate the clinical functions with resultant poor prognosis. Beside the hyper catabolic state frequently encountered in chronic liver disease and HCC, anorexia and reduced food intake also worsen the malnutrition. The recently discovered peptide hormone ghrelin acts as a counterpart of leptin in regulation of food intake and fat utilization. The aim of the present study was to investigate the ghrelin and leptin levels in cirrhosis and HCC due to hepatitis B and D viruses, and the association of ghrelin and leptin with TNF-α, IL-6 and the severity of the disease. Materials and methods. We measured serum ghrelin, leptin, TNF-α, and IL-6 levels using specific immunoassay in 45 patients (23 cirrhosis, 22 HCC) with HBV and/or HDV and in 25 control subjects. Results. In comparison to controls, serum ghrelin, TNF-α, and IL-6 levels were significantly higher in cirrhosis and HCC (P < .05), whereas serum leptin levels were found decreased (P < .05). There was a positive correlation between ghrelin and TNF-α, and a negative correlation between leptin and TNF-α (P < .05). Conclusion. In cirrhosis and HCC due to HBV or HDV, serum ghrelin levels were increased with a corresponding decrease in serum leptin concentrations, acting as a physiological counterpart of ghrelin. The increasing of ghrelin is more prominent in Child C cirrhosis and the level was correlated with TNF-α. The presence of nutritional and metabolic abnormalities, including malnutrition, in cirrhosis and HCC may, at least partly, elucidate high ghrelin and low leptin levels.

Nutrition in end stage liver disease

This chapter will focus on studies within the last 5 years of nutrition in end stage liver disease, but earlier studies illustrating the present state of affairs will also be mentioned. The first part will focus on descriptive epidemiological studies that help to set the scene for the intervention studies, which will be described in the second part. Each part will discuss liver cirrhosis, acute liver failure and liver transplantation separately. The aim is to provide the reader with sufficient background for the decision in clinical practice about when to see nutrition support as an important part of treatment of the patient.

Nutrition in liver disease

PURPOSE OF REVIEW

The aim of this paper is to describe the relevant medical literature published between spring 2003 and spring 2005 in the field of malnutrition in liver disease and its management.

RECENT FINDINGS

The most relevant articles covered in this paper provide data regarding the absence of energy imbalance in patients with stable cirrhosis, thus arguing against its potential role in the development of malnutrition; the increase in body cell mass and muscle mass as the major components of weight gain after portal-systemic shunting; the largest published randomized controlled trial of the positive effect of branched-chain amino acid supplements on the long-term outcome of patients with cirrhosis; studies using stable isotope labeled substrates, suggesting that dietary fat could be absorbed via the portal vein in patients with cirrhosis; and a randomized controlled trial suggesting the possibility that probiotics may decrease the infection rate after liver transplantation.

SUMMARY

In spite of the data provided by these and other articles described in the review, the major controversial issues in the field of nutritional management of liver disease remain open. Particularly remarkable is the lack of consensus regarding the nutritional management of acute liver failure.

Effects of an appropriate oral diet on the nutritional status of patients with HCV-related liver cirrhosis: a prospective study

BACKGROUND AND AIMS

In patients with liver cirrhosis, protein-energy malnutrition is a frequent finding and a risk factor influencing survival. The aim was to estimate the effects of an adequate diet on malnutrition and clinical outcome in patients with Child A or B HCV-related liver cirrhosis.

METHODS

We enrolled 90 consecutive outpatients (M/F=52/38) with liver cirrhosis, 30 in Child class A and 60 in class B. Patients were evaluated by anamnesis, clinical examination, estimation of daily caloric intake and measurement of anthropometrical and biochemical indexes. Patients were randomized into two groups: group 1 with a 3-month oral controlled diet started one week after the first examination and this was followed by a 3-month of spontaneous dietary intake, and group 2 which started a 3-month spontaneous dietary intake followed by a 3-month of controlled diet. The follow-up was performed every month.

RESULTS

During the period of controlled diet in patients of both groups, protein malnutrition assessed by midarm muscle circumference, creatinine-height index and serum albumin significantly improved independently of the Child class. Lipid malnutrition, assessed by triceps skin fold thickness values, did not improve during the course of the study. The compliance to the prescribed diet was very high in both groups, and no carry over effect of the previous dietary intake was observed during the follow-up period.

CONCLUSIONS

The results emphasize the importance of both nutritional status evaluation and improvement in the Child A and B cirrhotic patients with HCV-related disease. The proposed nutritional approach was able to influence their protein malnutrition positively.