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Santangeli E, Abbati C, Chen R, Di Carlo A, Leoni S, Piscaglia F, Ferri S. Pathophysiological-Based Nutritional Interventions in Cirrhotic Patients with Sarcopenic Obesity: A State-of-the-Art Narrative Review. Nutrients 2024; 16:427. [PMID: 38337711 PMCID: PMC10857546 DOI: 10.3390/nu16030427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
In recent decades, following the spread of obesity, metabolic dysfunction has come to represent the leading cause of liver disease. The classical clinical presentation of the cirrhotic patient has, therefore, greatly changed, with a dramatic increase in subjects who appear overweight or obese. Due to an obesogenic lifestyle (lack of physical activity and overall malnutrition, with an excess of caloric intake together with a deficit of proteins and micronutrients), these patients frequently develop a complex clinical condition defined as sarcopenic obesity (SO). The interplay between cirrhosis and SO lies in the sharing of multiple pathogenetic mechanisms, including malnutrition/malabsorption, chronic inflammation, hyperammonemia and insulin resistance. The presence of SO worsens the outcome of cirrhotic patients, affecting overall morbidity and mortality. International nutrition and liver diseases societies strongly agree on recommending the use of food as an integral part of the healing process in the comprehensive management of these patients, including a reduction in caloric intake, protein and micronutrient supplementation and sodium restriction. Based on the pathophysiological paths shared by cirrhosis and SO, this narrative review aims to highlight the nutritional interventions currently advocated by international guidelines, as well as to provide hints on the possible role of micronutrients and nutraceuticals in the treatment of this multifaceted clinical condition.
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Affiliation(s)
- Ernestina Santangeli
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (E.S.); (C.A.); (R.C.); (F.P.)
| | - Chiara Abbati
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (E.S.); (C.A.); (R.C.); (F.P.)
| | - Rusi Chen
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (E.S.); (C.A.); (R.C.); (F.P.)
| | - Alma Di Carlo
- Division of Internal Medicine, Hepatobiliary and Immunoallergologic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.D.C.); (S.L.)
| | - Simona Leoni
- Division of Internal Medicine, Hepatobiliary and Immunoallergologic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.D.C.); (S.L.)
| | - Fabio Piscaglia
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (E.S.); (C.A.); (R.C.); (F.P.)
- Division of Internal Medicine, Hepatobiliary and Immunoallergologic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.D.C.); (S.L.)
| | - Silvia Ferri
- Division of Internal Medicine, Hepatobiliary and Immunoallergologic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.D.C.); (S.L.)
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Qasim Agha O, Alsayid M, Reynolds J. Nasoenteric Tube Placement in Patients with Esophageal Varices: A Review of the Current Evidence and Society Guidelines. Avicenna J Med 2023; 13:193-198. [PMID: 38144911 PMCID: PMC10736187 DOI: 10.1055/s-0043-1776338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2023] Open
Abstract
Esophageal varices are a common complication of portal hypertension and variceal bleeding can be associated with significant morbidity and mortality. Hospitalized patients with cirrhosis might require nasoenteric tube (NET) placement, commonly for nutritional support and/or medication administration. However, the fear of causing massive variceal bleeding among clinicians might lead to hesitancy or complete avoidance of NET placement in patients who either have a known history of esophageal varices or are at risk to have them. Several experts and society guidelines addressed this concern with variable recommendations and degrees of evidence. In this article, we present an extensive review of the literature and latest society guidelines that address the safety of NET placement in patients with esophageal varices.
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Affiliation(s)
- Osama Qasim Agha
- Department of Internal Medicine, Creighton University School of Medicine, Phoenix, Arizona, United States
- Department of Internal Medicine, St Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
- Department of Internal Medicine, University of Arizona College of Medicine, Phoenix, Arizona, United States
| | - Muhammad Alsayid
- Division of Digestive Diseases, Rush University Medical Center, Chicago, Illinois, United States
| | - Justin Reynolds
- Department of Internal Medicine, Creighton University School of Medicine, Phoenix, Arizona, United States
- Center for Liver and Hepatobiliary Disease, St Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
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Ullah MI, Alameen AAM, Al-Oanzi ZH, Eltayeb LB, Atif M, Munir MU, Ejaz H. Biological Role of Zinc in Liver Cirrhosis: An Updated Review. Biomedicines 2023; 11:biomedicines11041094. [PMID: 37189711 DOI: 10.3390/biomedicines11041094] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/01/2023] [Accepted: 04/02/2023] [Indexed: 05/17/2023] Open
Abstract
Liver cirrhosis is a complication usually due to the consequence of persistent chronic liver disease. It is associated with different mechanisms, including hypoalbuminemia, impaired amino acid turnover, and micronutrient deficiencies. Consequently, cirrhotic patients can develop progressive complications like ascites, hepatic encephalopathy, and hepatocellular carcinoma. The liver is a vital organ that regulates the different metabolic pathways and transportation of trace elements. Zn is an indispensable micronutrient trace element involved in its crucial functions in cellular metabolic activity. Zn mediates its action by binding to a wide range of proteins; therefore, it imparts numerous biological effects, including cellular division, differentiation, and growth. It is also involved in critical processes for the biosynthesis of structural proteins and regulation of transcription factors and acts as a co-factor for the various enzymatic processes. As the liver is a significant regulator of Zn metabolism, its abnormalities lead to Zn deficiency, which has consequences on cellular, endocrine, immune, sensory, and skin dysfunctions. Conversely, Zn deficiency may modify the functions of hepatocytes and immune responses (acute phase protein production) in inflammatory liver diseases. This review has concisely stated the evolving indication of the critical role of Zn in biological processes and complications associated with liver cirrhosis pathogenesis due to Zn deficiency.
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Affiliation(s)
- Muhammad Ikram Ullah
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Jouf University, Sakaka 72388, Aljouf, Saudi Arabia
| | - Ayman Ali Mohammed Alameen
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Jouf University, Sakaka 72388, Aljouf, Saudi Arabia
| | - Ziad H Al-Oanzi
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Jouf University, Sakaka 72388, Aljouf, Saudi Arabia
| | - Lienda Bashier Eltayeb
- Department of Medical Laboratory Sciences, College of Applied Medical Sciences, Prince Sattam Bin Abdul Aziz University, Al-Kharj 11942, Riyadh, Saudi Arabia
| | - Muhammad Atif
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Jouf University, Sakaka 72388, Aljouf, Saudi Arabia
| | - Muhammad Usman Munir
- Department of Pharmaceutical Chemistry, College of Pharmacy, Jouf University, Sakaka 72388, Aljouf, Saudi Arabia
| | - Hasan Ejaz
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Jouf University, Sakaka 72388, Aljouf, Saudi Arabia
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Matsumoto Y, Fujii H, Harima M, Okamura H, Yukawa-Muto Y, Odagiri N, Motoyama H, Kotani K, Kozuka R, Kawamura E, Hagihara A, Uchida-Kobayashi S, Enomoto M, Yasui Y, Habu D, Kawada N. Severity of Liver Fibrosis Is Associated with the Japanese Diet Pattern and Skeletal Muscle Mass in Patients with Nonalcoholic Fatty Liver Disease. Nutrients 2023; 15:nu15051175. [PMID: 36904174 PMCID: PMC10005291 DOI: 10.3390/nu15051175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/20/2023] [Accepted: 02/24/2023] [Indexed: 03/02/2023] Open
Abstract
It is not fully clear as to which dietary patterns are associated with the pathogenesis of nonalcoholic fatty liver disease (NAFLD) in Asia. We conducted a cross-sectional study of 136 consecutively recruited patients with NAFLD (49% female, median age 60 years). Severity of liver fibrosis was assessed using the Agile 3+ score, a recently proposed system based on vibration-controlled transient elastography. Dietary status was assessed using the 12-component modified Japanese diet pattern index (mJDI12). Skeletal muscle mass was assessed by bioelectrical impedance. Factors associated with intermediate-high-risk Agile 3+ scores and skeletal muscle mass (75th percentile or higher) were analyzed by multivariable logistic regression. After adjustment for confounders, such as age and sex, the mJDI12 (OR: 0.77; 95% CI: 0.61, 0.99) and skeletal muscle mass (75th percentile or higher) (OR: 0.23; 95% CI: 0.07, 0.77) were significantly associated with intermediate-high-risk Agile 3+ scores. Soybeans and soybean foods were significantly associated with skeletal muscle mass (75th percentile or higher) (OR: 1.02; 95% CI: 1.00, 1.04). In conclusion, the Japanese diet pattern was associated with the severity of liver fibrosis in Japanese patients with NAFLD. Skeletal muscle mass was also associated with the severity of liver fibrosis, and intake of soybeans and soybean foods.
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Affiliation(s)
- Yoshinari Matsumoto
- Department of Nutrition, Graduate School of Human Life and Ecology, Osaka Metropolitan University, 3-7-30 Habikino, Habikino-shi, Osaka 583-8555, Japan
| | - Hideki Fujii
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
- Correspondence: ; Tel.: +81-6-6645-3905
| | - Mika Harima
- Nutrition Department, Osaka Metropolitan University Hospital, 1-5-7 Asahimachi, Abeno-ku, Osaka 545-8586, Japan
| | - Haruna Okamura
- Nutrition Department, Osaka Metropolitan University Hospital, 1-5-7 Asahimachi, Abeno-ku, Osaka 545-8586, Japan
| | - Yoshimi Yukawa-Muto
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Naoshi Odagiri
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Hiroyuki Motoyama
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Kohei Kotani
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Ritsuzo Kozuka
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Etsushi Kawamura
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Atsushi Hagihara
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Sawako Uchida-Kobayashi
- Department of Premier Preventive Medicine, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abenoku, Osaka 545-8585, Japan
| | - Masaru Enomoto
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Yoko Yasui
- Department of Nutrition, Graduate School of Human Life and Ecology, Osaka Metropolitan University, 3-7-30 Habikino, Habikino-shi, Osaka 583-8555, Japan
| | - Daiki Habu
- Department of Nutrition, Graduate School of Human Life and Ecology, Osaka Metropolitan University, 3-7-30 Habikino, Habikino-shi, Osaka 583-8555, Japan
| | - Norifumi Kawada
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
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Ngu NL, Saxby E, Worland T, Anderson P, Stothers L, Figredo A, Hunter J, Elford A, Ha P, Hartley I, Roberts A, Seah D, Tambakis G, Liew D, Rogers B, Sievert W, Bell S, Le S. A home-based, multidisciplinary liver optimisation programme for the first 28 days after an admission for acute-on-chronic liver failure (LivR well): a study protocol for a randomised controlled trial. Trials 2022; 23:744. [PMID: 36064596 PMCID: PMC9444080 DOI: 10.1186/s13063-022-06679-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 08/20/2022] [Indexed: 11/22/2022] Open
Abstract
Background Acute-on-chronic liver failure (ACLF) represents a rising global healthcare burden, characterised by increasing prevalence among patients with decompensated cirrhosis who have a 28-day transplantation-free mortality of 33.9%. Due to disease complexity and a high prevalence of socio-economic disadvantage, there are deficits in quality of care and adherence to guideline-based treatment in this cohort. Compared to other chronic conditions such as heart failure, those with liver disease have reduced access to integrated ambulatory care services. The LivR Well programme is a multidisciplinary intervention aimed at improving 28-day mortality and reducing 30-day readmission through a home-based, liver optimisation programme implemented in the first 28 days after an admission with either ACLF or hepatic decompensation. Outcomes from our feasibility study suggest that the intervention is safe and acceptable to patients and carers. Methods We will recruit adult patients with chronic liver disease from the emergency departments, in-patient admissions, and an ambulatory liver clinic of a multi-site quaternary health service in Melbourne, Australia. A total of 120 patients meeting EF-Clif criteria will be recruited to the ACLF arm, and 320 patients to the hepatic decompensation arm. Participants in each cohort will be randomised to the intervention arm, a 28-day multidisciplinary programme or to standard ambulatory care in a 1:1 ratio. The intervention arm includes access to nursing, pharmacy, physiotherapy, dietetics, social work, and neuropsychiatry clinicians. For the ACLF cohort, the primary outcome is 28-day mortality. For the hepatic decompensation cohort, the primary outcome is 30-day re-admission. Secondary outcomes assess changes in liver disease severity and quality of life. An interim analysis will be performed at 50% recruitment to consider early cessation of the trial if the intervention is superior to the control, as suggested in our feasibility study. A cost-effectiveness analysis will be performed. Patients will be followed up for 12 weeks from randomisation. Three exploratory subgroup analyses will be conducted by (a) source of referral, (b) unplanned hospitalisation, and (c) concurrent COVID-19. The trial has been registered with the Australian New Zealand Clinical Trials Registry. Discussion This study implements a multidisciplinary intervention for ACLF patients with proven benefits in other chronic diseases with the addition of novel digital health tools to enable remote patient monitoring during the COVID-19 pandemic. Our feasibility study demonstrates safety and acceptability and suggests clinical improvement in a small sample size. An RCT is required to generate robust outcomes in this frail, high healthcare resource utilisation cohort with high readmission and mortality risk. Interventions such as LivR Well are urgently required but also need to be evaluated to ensure feasibility, replicability, and scalability across different healthcare systems. The implications of this trial include the generalisability of the programme for implementation across regional and urban centres. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621001703897. Registered on 13 December 2021. WHO Trial Registration Data Set. See Appendix 1 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06679-x.
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Affiliation(s)
- Natalie Ly Ngu
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia. .,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia.
| | - Edward Saxby
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Thomas Worland
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Patricia Anderson
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Lisa Stothers
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Anita Figredo
- Hospital in the Home, Level 4, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Jo Hunter
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Alexander Elford
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Phil Ha
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Imogen Hartley
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Andrew Roberts
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Dean Seah
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - George Tambakis
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Danny Liew
- Adelaide Medical School, The University of Adelaide, Corner of North Terrace & George St, Adelaide, South Australia, 5000, Australia
| | - Benjamin Rogers
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia.,Hospital in the Home, Level 4, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - William Sievert
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
| | - Sally Bell
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
| | - Suong Le
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
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Protein Catabolism and the Dysregulation of Energy Intake-Related Hormones May Play a Major Role in the Worsening of Malnutrition in Hospitalized Cirrhotic Patients. LIVERS 2022. [DOI: 10.3390/livers2030014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Malnutrition in cirrhotic patients is extremely common and has a multifactorial aetiology, whose constitutive elements have not been completely elucidated yet. Protein depletion is particularly important and an imbalance of hormones regulating hunger and satiety may be an important additive factor. The diagnosis and treatment of malnutrition are extremely important since malnutrition is associated with higher complication rates and mortality. Our observational study aimed to study protein status and energy intake-related hormone levels in a cohort of hospitalized cirrhotic patients. We enrolled 50 hospitalized and clinically stable cirrhotic patients and assessed their nutritional status with anthropometric measurements and nitrogen balance. In a subgroup of 16 patients and 10 healthy controls, circulating ghrelin and leptin levels were studied. We observed that 60% of our patients were malnourished on the basis of the mid-arm muscle circumference values; the recorded daily protein intake was tendentially insufficient (mean protein intake of 0.7 ± 0.5 g protein/kg vs. recommended intake of 1.2–1.5 g of protein/kg/die). Cirrhotic patients had lower circulating levels of both ghrelin and leptin compared to healthy controls. In conclusion, hospitalized cirrhotic patients face a catabolic state and an imbalance in hormones regulating food intake and satiety, and these elements may play a major role in the genesis and/or the worsening of malnutrition.
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Abstract
Malnutrition is common in chronic liver diseases and worsens the patient’s prognosis. Many liver disorders are associated with nutritional deficiencies. Some of the main factors that can lead to malnutrition in patients with chronic liver disease include decreased lipid absorption and reduced albumin production. In addition, these patients are sometimes candidates for a liver transplant that requires nutritional intervention after surgery to improve their prognosis. Thus, it is very important to recognise malnutrition in patients with liver failure in order to resolve it, mainly by a complete history of the patient, dietary survey, determination of muscle mass and a subjective assessment. To ensure a good nutritional status, exercise and lifestyle changes are considered, including dietary modifications, especially with a Mediterranean pattern. This article reviews these topics, including dietary modifications before and after liver transplantation. Additionally, nutritional recommendations are offered to patients with metabolic hepatic steatosis.
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Iqbal U, Jadeja RN, Khara HS, Khurana S. A Comprehensive Review Evaluating the Impact of Protein Source (Vegetarian vs. Meat Based) in Hepatic Encephalopathy. Nutrients 2021; 13:nu13020370. [PMID: 33530344 PMCID: PMC7911290 DOI: 10.3390/nu13020370] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 02/07/2023] Open
Abstract
Hepatic encephalopathy (HE) is a common neurological consequence in patients with cirrhosis and has a healthcare burden of USD 5370 to 50,120 per patient annually. HE significantly hampers the quality of life and is a major cause of morbidity and mortality. Patients with cirrhosis are at a high risk for protein-calorie malnutrition due to altered metabolism. Current evidence has changed the old belief of protein restriction in patients with cirrhosis and now 1.2 to 1.5 g/kg/day protein intake is recommended. Case series and studies with small numbers of participants showed that a vegetarian protein diet decreases the symptoms of HE when compared to a meat-based diet, but the evidence is limited and requires further larger randomized controlled trials. However, vegetable or milk-based protein diets are good substitutes for patients averse to meat intake. Branch chain amino acids (BCAA) (leucine, isoleucine and valine) have also been shown to be effective in alleviating symptoms of HE and are recommended as an alternative therapy in patients with cirrhosis for the treatment of HE. In this review, we provide an overview of current literature evaluating the role of protein intake in the management of HE in cirrhosis.
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Affiliation(s)
- Umair Iqbal
- Geisinger Medical Center, Department of Gastroenterology and Hepatology, Danville, PA 17822, USA; (U.I.); (H.S.K.)
| | - Ravirajsinh N. Jadeja
- Department of Biochemistry and Molecular Biology, The Medical College of Georgia at Augusta University, Augusta, GA 30912, USA;
| | - Harshit S. Khara
- Geisinger Medical Center, Department of Gastroenterology and Hepatology, Danville, PA 17822, USA; (U.I.); (H.S.K.)
| | - Sandeep Khurana
- Geisinger Medical Center, Department of Gastroenterology and Hepatology, Danville, PA 17822, USA; (U.I.); (H.S.K.)
- Correspondence: ; Tel.: +1-570-271-6407
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Lai R, Chen T, Wu Z, Lin S, Zhu Y. Associations between body mass index and mortality in acute-on-chronic liver failure patients. Ann Hepatol 2020; 18:893-897. [PMID: 31506215 DOI: 10.1016/j.aohep.2019.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 07/15/2019] [Accepted: 07/18/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION AND OBJECTIVES The association between the level of body mass index (BMI) and the mortality of patients with critical liver disease remains unclear. This study aimed to examine the association between BMI and hospital mortality of patients with acute-on-chronic liver failure (ACLF). METHODS Clinical data from 146 ACLF patients were collected and analyzed. BMI was categorized into three groups: lower BMI (<18.5kg/m2), normal BMI (18.5-24.9kg/m2), and overweight (25.0-32.0kg/m2). BMI and laboratory parameters were measured one day before, or on the day of the start of the treatment. Values of BMI and laboratory parameters were compared between survivors and non-survivors, and then hospital mortality rates were compared among patients with different BMI levels. RESULTS The prognosis of ACLF patients was significantly correlated with international normalized ratio (INR), albumin and BMI. The ACLF patients with low albumin level and high INR values tend to have a high mortality rate. Also, survival time was significantly shorter in the ACLF patients with lower BMI, while patients with normal and overweight values had longer survival time. CONCLUSIONS A graded association between BMI and hospital mortality with a strong significant trend was found in ACLF patients in China.
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Affiliation(s)
- Ruimin Lai
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Tianbin Chen
- Department of Laboratory Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zimu Wu
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Su Lin
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yueyong Zhu
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China.
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10
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Current Status and Prospects of Spontaneous Peritonitis in Patients with Cirrhosis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3743962. [PMID: 32724800 PMCID: PMC7364234 DOI: 10.1155/2020/3743962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/03/2020] [Indexed: 12/14/2022]
Abstract
Spontaneous bacterial peritonitis (SBP) is a common cirrhotic ascites complication which exacerbates the patient's condition. SBP is caused by gram-negative bacilli and, to a lesser extent, gram-positive cocci. Hospital-acquired infections show higher levels of drug-resistant bacteria. Geographical location influences pathogenic bacteria distribution; therefore, different hospitals in the same country record different bacteria strains. Intestinal changes and a weak immune system in patients with liver cirrhosis lead to bacterial translocation thus causing SBP. Early diagnosis and timely treatment are important in SBP management. When the treatment effect is not effective, other rare pathogens should be explored.
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Affiliation(s)
- Manuela Merli
- Sapienza University of Rome, Department of Translational and Precision Medicine, Gastroenterology and Hepatology Unit, Rome, Italy.
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12
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Merli M. Pediatric sarcopenia: exploring a new concept in children with chronic liver disease. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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13
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Millson C, Considine A, Cramp ME, Holt A, Hubscher S, Hutchinson J, Jones K, Leithead J, Masson S, Menon K, Mirza D, Neuberger J, Prasad R, Pratt A, Prentice W, Shepherd L, Simpson K, Thorburn D, Westbrook R, Tripathi D. Adult liver transplantation: A UK clinical guideline - part 1: pre-operation. Frontline Gastroenterol 2020; 11:375-384. [PMID: 32879721 PMCID: PMC7447286 DOI: 10.1136/flgastro-2019-101215] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 02/04/2023] Open
Abstract
Liver transplantation is a highly successful treatment for all types of liver failure, some non-liver failure indications and liver cancer. Most referrals come from secondary care. This first part of a two-part guideline outlines who to refer, and how that referral should be made, including patient details and additional issues such as those relevant to alcohol and drug misuse. The process of liver transplant assessment involves the confirmation of the diagnosis and non-reversibility, an evaluation of comorbidities and exclusion of contraindications. Finally, those making it onto the waiting list require monitoring and optimising. Underpinning this process is a need for good communication between patient, their carers, secondary care and the liver transplant service, synchronised by the transplant coordinator. Managing expectation and balancing the uncertainty of organ availability against the inevitable progression of underlying liver disease requires sensitivity and honesty from all healthcare providers and the assessment of palliative care needs is an integral part of this process.
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Affiliation(s)
- Charles Millson
- Department of Hepatology, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Aisling Considine
- Pharmacy department, King's College Hospital NHS Foundation Trust, London, UK
| | - Matthew E Cramp
- South West Liver Unit, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Andrew Holt
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stefan Hubscher
- Department of Cellular Pathology, University of Birmingham, Birmingham, UK
| | - John Hutchinson
- Department of Hepatology, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Kate Jones
- Liver Transplantation Service, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joanna Leithead
- Department of Hepatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Steven Masson
- Liver Unit, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Krish Menon
- Liver Transplantation & HPB Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Darius Mirza
- Liver Transplantation & HPB surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James Neuberger
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Raj Prasad
- Liver Transplantation & HPB Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Anthony Pratt
- Pharmacy department, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Wendy Prentice
- Palliative Care Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Liz Shepherd
- Liver Transplantation Service, Royal Free London NHS Foundation Trust, London, UK
| | - Ken Simpson
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Doug Thorburn
- Department of Hepatology, Royal Free London NHS Foundation Trust, London, UK
| | - Rachel Westbrook
- Department of Hepatology, Royal Free London NHS Foundation Trust, London, UK
| | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birminghams, UK
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14
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Kozeniecki M, Ludke R, Kerner J, Patterson B. Micronutrients in Liver Disease: Roles, Risk Factors for Deficiency, and Recommendations for Supplementation. Nutr Clin Pract 2019; 35:50-62. [PMID: 31840874 DOI: 10.1002/ncp.10451] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Micronutrients are essential components of the diet and are required to maintain fundamental bodily functions. Liver disease has a profound effect on nutrient intake, metabolism of nutrients, and nutrition status, often resulting in some degree of malnutrition, including micronutrient deficiency. Vitamin and mineral deficiencies can impair metabolic processes at the cellular and biochemical level even before clinical and physical alterations are seen. It is essential that micronutrient status is evaluated as part of a comprehensive nutrition assessment for all patients with chronic or advanced liver disease. Early intervention to correct suspected or confirmed deficiencies may minimize symptoms and improve clinical outcomes and quality of life. In this narrative review, different types of liver disease and associated micronutrient abnormalities are outlined, and methods of micronutrient assessment and supplementation are discussed.
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Affiliation(s)
- Michelle Kozeniecki
- Department of Nutrition Services, Froedtert Hospital, Milwaukee, Wisconsin, USA
| | - Rachel Ludke
- Department of Nutrition Services, Froedtert Hospital, Milwaukee, Wisconsin, USA
| | - Jennifer Kerner
- Transplant Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Brittney Patterson
- Clinical Nutrition Department, Stanford Health Care, Stanford, California, USA
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15
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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.
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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
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16
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Pesce M, Magee C, Holloway RH, Gyawali CP, Roman S, Pioche M, Savarino E, Quader F, Sarnelli G, Sanagapalli S, Bredenoord AJ, Sweis R. The treatment of achalasia patients with esophageal varices: an international study. United European Gastroenterol J 2019; 7:565-572. [PMID: 31065374 DOI: 10.1177/2050640619838114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/22/2019] [Indexed: 01/10/2023] Open
Abstract
Background Treatment options for achalasia include endoscopic and surgical techniques that carry the risk of esophageal bleeding and perforation. The rare coexistence of esophageal varices has only been anecdotally described and treatment is presumed to carry additional risk. Methods Experience from physicians/surgeons treating this rare combination of disorders was sought through the International Manometry Working Group. Results Fourteen patients with achalasia and varices from seven international centers were collected (mean age 61 ± 9 years). Five patients were treated with botulinum toxin injections (BTI), four had dilation, three received peroral endoscopic myotomy (POEM), one had POEM then dilation, and one patient underwent BTI followed by Heller's myotomy. Variceal eradication preceded achalasia treatment in three patients. All patients experienced a significant symptomatic improvement (median Eckardt score 7 vs 1; p < 0.0001) at 6 months follow-up, with treatment outcomes resembling those of 20 non-cirrhotic achalasia patients who underwent similar therapy. No patients had recorded complications of bleeding or perforation. Conclusion This study shows an excellent short-term symptomatic response in patients with esophageal achalasia and varices and demonstrates that the therapeutic outcomes and complications, other than transient encephalopathy in both patients who had a portosystemic shunt, did not differ to disease-matched patients without varices.
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Affiliation(s)
- M Pesce
- Department of Gastroenterology, Department of GI Physiology, University College London Hospitals, London, UK.,University of Naples "Federico II", Naples, Italy
| | - C Magee
- Department of Gastroenterology, Department of GI Physiology, University College London Hospitals, London, UK
| | | | - C P Gyawali
- Division of Gastroenterology, Washington University, St Louis, MO, USA
| | - S Roman
- Department of Gastroenterology, Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - M Pioche
- Department of Gastroenterology, Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | | | - F Quader
- Division of Gastroenterology, Washington University, St Louis, MO, USA
| | - G Sarnelli
- University of Naples "Federico II", Naples, Italy
| | - S Sanagapalli
- Department of Gastroenterology, Department of GI Physiology, University College London Hospitals, London, UK.,St. Vincent's Hospital Sydney, Sydney, Australia
| | - A J Bredenoord
- Division of Gastroenterology and Hepatology, Amsterdam Medical Centre, Amsterdam, Netherlands
| | - R Sweis
- Department of Gastroenterology, Department of GI Physiology, University College London Hospitals, London, UK
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17
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Rohm M, Zeigerer A, Machado J, Herzig S. Energy metabolism in cachexia. EMBO Rep 2019; 20:embr.201847258. [PMID: 30890538 DOI: 10.15252/embr.201847258] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/11/2019] [Accepted: 02/05/2019] [Indexed: 12/26/2022] Open
Abstract
Cachexia is a wasting disorder that accompanies many chronic diseases including cancer and results from an imbalance of energy requirements and energy uptake. In cancer cachexia, tumor-secreted factors and/or tumor-host interactions cause this imbalance, leading to loss of adipose tissue and skeletal and cardiac muscle, which weakens the body. In this review, we discuss how energy enters the body and is utilized by the different organs, including the gut, liver, adipose tissue, and muscle, and how these organs contribute to the energy wasting observed in cachexia. We also discuss futile cycles both between the organs and within the cells, which are often used to fine-tune energy supply under physiologic conditions. Ultimately, understanding the complex interplay of pathologic energy-wasting circuits in cachexia can bring us closer to identifying effective treatment strategies for this devastating wasting disease.
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Affiliation(s)
- Maria Rohm
- Institute for Diabetes and Cancer (IDC), Helmholtz Center Munich, Neuherberg, Germany.,Joint Heidelberg-IDC Translational Diabetes Program, Inner Medicine I, Heidelberg University Hospital, Heidelberg, Germany
| | - Anja Zeigerer
- Institute for Diabetes and Cancer (IDC), Helmholtz Center Munich, Neuherberg, Germany.,Joint Heidelberg-IDC Translational Diabetes Program, Inner Medicine I, Heidelberg University Hospital, Heidelberg, Germany
| | - Juliano Machado
- Institute for Diabetes and Cancer (IDC), Helmholtz Center Munich, Neuherberg, Germany.,Joint Heidelberg-IDC Translational Diabetes Program, Inner Medicine I, Heidelberg University Hospital, Heidelberg, Germany
| | - Stephan Herzig
- Institute for Diabetes and Cancer (IDC), Helmholtz Center Munich, Neuherberg, Germany .,Joint Heidelberg-IDC Translational Diabetes Program, Inner Medicine I, Heidelberg University Hospital, Heidelberg, Germany.,Chair Molecular Metabolic Control, Technical University Munich, Munich, Germany
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18
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Rachakonda V, Argemi J, Borhani AA, Bataller R, Tevar A, Behari J. Reduced Serum Sphingolipids Constitute a Molecular Signature of Malnutrition in Hospitalized Patients With Decompensated Cirrhosis. Clin Transl Gastroenterol 2019; 10:e00013. [PMID: 30908309 PMCID: PMC6445606 DOI: 10.14309/ctg.0000000000000013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 12/14/2018] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Malnutrition is a leading cause of morbidity and mortality in cirrhosis. Although multiple noninvasive measures of nutritional status have been studied, no consensus exists for early identification of malnutrition in cirrhosis. Serum metabolomics offers a novel approach for identifying biomarkers in multiple disease states. To characterize alterations in metabolic pathways associated with malnutrition in hospitalized cirrhotic patients and to identify biomarkers for disease prognosis. METHODS In this cross-sectional, observational cohort study, 51 hospitalized cirrhotic patients were classified as malnourished (42.3%) or nourished (57.7%) based on low mid-arm muscle circumference and dominant handgrip strength. Anthropometric measurements and computed tomography body composition analysis were performed. Serum was collected after overnight fasting for unbiased metabolomics analysis. RESULTS Malnourished cirrhotic patients exhibited mild reductions in skeletal muscle index, with more marked reductions in visceral fat index. Seventy-one biochemicals were significantly altered in malnourished subjects. The serum metabolite profile was significantly different between nourished and malnourished cirrhotic patients. Pathway analysis demonstrated that only sphingolipid metabolic pathways were significantly enriched in altered metabolites. Hierarchical clustering revealed that sphingolipid metabolites clustered into nourished and malnourished cohorts. Spearman analysis demonstrated multiple statistically significant correlations between sphingolipid species and Model for End-Stage Liver Disease-Sodium. Using logistic regression, we identified 8 sphingolipids that were significantly associated with malnutrition after controlling for Model for End-Stage Liver Disease-Sodium, age, and gender. CONCLUSIONS Malnutrition in hospitalized cirrhotic patients is characterized by reductions in multiple sphingolipid species. Dysregulated sphingolipid metabolism may be involved in the pathophysiology of malnutrition in cirrhosis and potentially serve as a biomarker of nutritional status in this population.
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Affiliation(s)
- Vikrant Rachakonda
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Josepmaria Argemi
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amir A. Borhani
- Department of Radiology, Division of Abdominal Imaging, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ramon Bataller
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amit Tevar
- Department of Surgery, Division Abdominal Transplantation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jaideep Behari
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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19
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Shergill R, Syed W, Rizvi SA, Singh I. Nutritional support in chronic liver disease and cirrhotics. World J Hepatol 2018; 10:685-694. [PMID: 30386461 PMCID: PMC6206154 DOI: 10.4254/wjh.v10.i10.685] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/04/2018] [Accepted: 08/06/2018] [Indexed: 02/06/2023] Open
Abstract
The liver is a major organ and an essential component in maintaining an appropriate nutritional status in healthy individuals through metabolism of protein, carbohydrates, and fat. In individuals with chronic liver disease (CLD), along with a number of other essential functions that the liver serves, its role in nutrition maintenance is severely impaired. Common causes of CLD include hepatitis C, alcoholic liver disease, and non-alcoholic liver disease. Amongst this population, the most common manifestation of impaired nutritional maintenance is protein-calorie malnutrition. Aside from inherent abnormalities in metabolism, such as malabsorption and maldigestion, CLD can be associated with anorexia as well as increased metabolic requirements, all of which contribute to a state of malnutrition. Given the systemic implications and impact on prognosis of malnutrition, proper nutritional assessment is essential and can be achieved through a thorough history and physical, as well as biochemical investigations and anthropometry as needed. Following an appropriate assessment of a patient’s nutritional status, an approach to management can be decided upon and is based on the extent of malnutrition which directly reflects the severity of disease. Management options can be grossly separated into enteral and parenteral nutrition. The former is usually sufficient in the form of oral supplements in less severe cases of malnutrition, but as the CLD worsens, parenteral nutrition becomes necessary. With appropriate assessment and early intervention, many of the complications of CLD can be avoided, and ultimately better outcomes can be achieved.
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Affiliation(s)
- Ravi Shergill
- Radiology Department, McMaster University, Hamilton, ON L8S4L8, Canada
| | - Wajahat Syed
- Undergraduate Medicine, McMaster University, Hamilton, ON L8S4L8, Canada
| | - Syed Ali Rizvi
- Undergraduate Medicine, McMaster University, Hamilton, ON L8S4L8, Canada
| | - Ikjot Singh
- Undergraduate Medicine, McMaster University, Hamilton, ON L8S4L8, Canada
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20
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Abstract
Liver cirrhosis is associated with significant nutritional risks that often result in serious hepatic complications and poor survival rates. Diet is an important but underutilized aspect in the treatment modality of cirrhosis. Therefore, the aims of this review are to ascertain nutritional risks associated with its pathophysiology and to summarize existing evidence that support dietary recommendations for managing this patient population. Alterations in substrate utilization for energy production is a main feature of liver cirrhosis, resulting in increased catabolism of protein stores and a predisposition toward protein-energy malnutrition, even in the early stages of the disease. The body of evidence suggests that a high energy and protein (>1.2 g/kg body weight/d) diet consumed frequently and late in the evening is effective in improving nutritional status of these patients and has been associated with improved hospitalization and mortality rates. The use of branched-chain amino acid supplementation shows promise in reducing cirrhosis-related complications but are currently limited by adverse gastrointestinal symptoms and poor palatability. Furthermore exploration of dietary manipulation of branched-chain amino acid warrants further examination. Evidence is also accumulating that protein intake should not be restricted in patients with hepatic encephalopathy with earlier studies of protein restriction neglecting to account for the relative increase in fermentable fiber which would reduce the absorption of ammonia into the portal system in a way similar to supplementation with lactulose. Finally, a major finding of this review is the need to improve the quality and quantity of dietary intervention studies for patients with liver cirrhosis, particularly with the use of partial or whole dietary sources. In conclusion, dietary management of cirrhosis is not a one-size fits all approach but should be implemented earlier on in the treatment algorithm to improve the clinical prognosis of cirrhosis.
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21
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Vasco M, Paolillo R, Schiano C, Sommese L, Cuomo O, Napoli C. Compromised nutritional status in patients with end-stage liver disease: Role of gut microbiota. Hepatobiliary Pancreat Dis Int 2018; 17:290-300. [PMID: 30173786 DOI: 10.1016/j.hbpd.2018.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with end-stage liver disease (ESLD) have a compromised nutritional status because of the liver crucial role in regulating metabolic homeostasis and energy balance. DATA SOURCES A systematic review of literature based on extensive relevant articles published from 2001 to 2017 in English in PubMed database was performed by searching keywords such as liver disease, non-alcoholic liver disease, alcoholic liver disease, malnutrition, epigenetics, gut microbiota, and probiotics. RESULTS Liver transplantation would be one eligible therapy for ESLD patients, even if, the clinical outcome is negatively influenced by malnutrition and/or infections. The malnutrition is a condition of nutrient imbalance with a high incidence in ESLD patients. An accurate evaluation of nutritional status could be fundamental for reducing complications and prolonging the survival of ESLD patients including those undergoing liver transplantation. In addition, the interaction among nutrients, diet and genes via epigenetics has emerged as a potential target to reduce the morbidity and mortality in ESLD patients. The malnutrition induces changes in gut microbiota causing dysbiosis with a probable translocation of bacteria and/or pathogen-derived factors from the intestine to the liver. Gut microbiota contribute to the progression of chronic liver diseases as well as hepatocellular carcinoma. The administration of probiotics modulating gut microbiota could improve all chronic liver diseases. CONCLUSIONS This review provides an update on malnutrition status linked to epigenetics and the potential benefit of some probiotics on the management of ESLD patients. In support of this view and to reveal the constant and growing interest in this field, some clinical trials are reported.
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Affiliation(s)
- Maria Vasco
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Regional Reference Laboratory of Transplant Immunology, Department of Internal and Specialty Medicine, Azienda Ospedaliera Universitaria, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy
| | - Rossella Paolillo
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Regional Reference Laboratory of Transplant Immunology, Department of Internal and Specialty Medicine, Azienda Ospedaliera Universitaria, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy
| | | | - Linda Sommese
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Regional Reference Laboratory of Transplant Immunology, Department of Internal and Specialty Medicine, Azienda Ospedaliera Universitaria, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy; Department of Experimental Medicine, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy.
| | - Oreste Cuomo
- Department of Liver Transplant, AORN A. Cardarelli, Naples, Italy
| | - Claudio Napoli
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Regional Reference Laboratory of Transplant Immunology, Department of Internal and Specialty Medicine, Azienda Ospedaliera Universitaria, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy; IRCCS SDN, Naples, Italy; Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
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22
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Han E, Lee YH, Kim BK, Park JY, Kim DY, Ahn SH, Lee BW, Kang ES, Cha BS, Han KH, Kim SU. Sarcopenia is associated with the risk of significant liver fibrosis in metabolically unhealthy subjects with chronic hepatitis B. Aliment Pharmacol Ther 2018; 48:300-312. [PMID: 29920701 DOI: 10.1111/apt.14843] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 11/02/2017] [Accepted: 05/20/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Sarcopenia is significantly associated with the degree of liver fibrosis. This study investigated the influence of sarcopenia on liver fibrosis in individuals with chronic hepatitis B. METHODS Data from the Korean National Health and Nutrition Examination Surveys 2008-2011 were analysed. The sarcopenia index (total appendicular skeletal muscle mass [kg]/body mass index [kg/m2 ]) was calculated using dual-energy X-ray absorptiometry. Sarcopenia was defined as the lowest quintile sarcopenia index value (cut-offs: 0.89 for men and 0.58 for women). The fibrotic burden was assessed using the nonalcoholic fatty liver disease fibrosis score and fibrosis-4 index. Significant fibrosis was defined as the highest nonalcoholic fatty liver disease fibrosis score quartile and a fibrosis-4 index ≥2.67. RESULTS Among the 506 respondents with chronic hepatitis B (258 men and 248 women), the nonalcoholic fatty liver disease fibrosis score and fibrosis-4 index identified sarcopenia and significant fibrosis in 126 (24.9%) and 217 (42.9%), respectively. Sarcopenia was significantly associated with significant fibrosis, regardless of the fibrosis prediction model used (all P < 0.05). When the study population was stratified according to metabolic factors, sarcopenia was specifically associated with an increased risk of significant fibrosis among subgroups with obesity, insulin resistance, metabolic syndrome and liver steatosis (odds ratio 2.37-3.57; all P < 0.05). An independent association between sarcopenia and significant fibrosis was identified after adjusting for other confounders (odds ratio 2.67-3.62 by the nonalcoholic fatty liver disease fibrosis score and 2.04-2.62 by the fibrosis-4 index; all P < 0.05). CONCLUSIONS Sarcopenia is associated with significant fibrosis in subjects with chronic hepatitis B, specifically those with obesity, insulin resistance, metabolic syndrome and liver steatosis.
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Affiliation(s)
- E Han
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Y-H Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Korea
| | - B K Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - J Y Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - D Y Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - S H Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - B-W Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Korea
| | - E S Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Korea
| | - B-S Cha
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Korea
| | - K-H Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - S U Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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23
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Kalafateli M, Karatzas A, Tsiaoussis G, Koutroumpakis E, Tselekouni P, Koukias N, Konstantakis C, Assimakopoulos S, Gogos C, Thomopoulos K, Kalogeropoulou C, Triantos C. Muscle fat infiltration assessed by total psoas density on computed tomography predicts mortality in cirrhosis. Ann Gastroenterol 2018; 31:491-498. [PMID: 29991895 PMCID: PMC6033770 DOI: 10.20524/aog.2018.0256] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 01/26/2018] [Indexed: 12/22/2022] Open
Abstract
Background: Ongoing evidence suggests that sarcopenia adversely affects outcomes in cirrhosis. The aim of this study was to evaluate muscle fat infiltration as a component of sarcopenia and its prognostic value in this setting. Methods: In 98 consecutive patients with cirrhosis, muscle density was measured during a computed tomography scan at the level of the fourth to fifth lumbar (L4) vertebrae. Univariate and multivariate Cox regression analysis was used to determine predictors of survival. Results: Body mass index: median 26 (range 17-45.2); model for end-stage liver disease (MELD) score: median 11 (6-29); Child-Pugh (CP) score: median 7 (5-13), CP class: A=49 (50.5%), B=39 (40%), C=10 (9.5%); hepatocellular carcinoma: 14 (14.3%); follow up: median 45 (1-140) months. Median L4 total psoas area (TPA): 2022 (777-3806) mm2; L4 average total psoas density (ATPD): 42.52 (21.26-59.8) HU. ATPD was significantly correlated with age (r=-0.222, P=0.034), creatinine (r=-0.41, P<0.001), albumin (r=0.224, P=0.035), MELD score (r=-0.218, P=0.034), and TPA (r=0.415, P<0.001). Fifty-four patients (55.1%) died during follow up. In the multivariate analysis, higher CP score (hazard ratio [HR] 1.2, 95% confidence interval [CI] 1.04-1.41), advanced age (HR 1.038, 95%CI 1.006-1.07) and lower ATPD (HR 0.967, 95%CI 0.937-0.997) were predictors of mortality. Conclusion: Muscle fat infiltration, as a result of sarcopenia, is a negative predictive factor of survival in cirrhosis, emphasizing the need for early identification of this subgroup of patients.
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Affiliation(s)
- Maria Kalafateli
- Department of Gastroenterology (Maria Kalafateli, Georgios Tsiaoussis, Efstratios Koutroubakis, Paraskevi Tselekouni, Nikolaos Koukias, Christos Konstantakis, Konstantinos Thomopoulos, Christos Triantos), University Hospital of Patras, Patras, Greece
| | - Andreas Karatzas
- Department of Radiology (Andreas Karatzas, Christina Kalogeropoulou), University Hospital of Patras, Patras, Greece
| | - Georgios Tsiaoussis
- Department of Gastroenterology (Maria Kalafateli, Georgios Tsiaoussis, Efstratios Koutroubakis, Paraskevi Tselekouni, Nikolaos Koukias, Christos Konstantakis, Konstantinos Thomopoulos, Christos Triantos), University Hospital of Patras, Patras, Greece
| | - Efstratios Koutroumpakis
- Department of Gastroenterology (Maria Kalafateli, Georgios Tsiaoussis, Efstratios Koutroubakis, Paraskevi Tselekouni, Nikolaos Koukias, Christos Konstantakis, Konstantinos Thomopoulos, Christos Triantos), University Hospital of Patras, Patras, Greece
| | - Paraskevi Tselekouni
- Department of Gastroenterology (Maria Kalafateli, Georgios Tsiaoussis, Efstratios Koutroubakis, Paraskevi Tselekouni, Nikolaos Koukias, Christos Konstantakis, Konstantinos Thomopoulos, Christos Triantos), University Hospital of Patras, Patras, Greece
| | - Nikolaos Koukias
- Department of Gastroenterology (Maria Kalafateli, Georgios Tsiaoussis, Efstratios Koutroubakis, Paraskevi Tselekouni, Nikolaos Koukias, Christos Konstantakis, Konstantinos Thomopoulos, Christos Triantos), University Hospital of Patras, Patras, Greece
| | - Christos Konstantakis
- Department of Gastroenterology (Maria Kalafateli, Georgios Tsiaoussis, Efstratios Koutroubakis, Paraskevi Tselekouni, Nikolaos Koukias, Christos Konstantakis, Konstantinos Thomopoulos, Christos Triantos), University Hospital of Patras, Patras, Greece
| | - Stelios Assimakopoulos
- Department of Internal Medicine (Stelios Assimakopoulos, Charalambos Gogos), University Hospital of Patras, Patras, Greece
| | - Charalambos Gogos
- Department of Internal Medicine (Stelios Assimakopoulos, Charalambos Gogos), University Hospital of Patras, Patras, Greece
| | - Konstantinos Thomopoulos
- Department of Gastroenterology (Maria Kalafateli, Georgios Tsiaoussis, Efstratios Koutroubakis, Paraskevi Tselekouni, Nikolaos Koukias, Christos Konstantakis, Konstantinos Thomopoulos, Christos Triantos), University Hospital of Patras, Patras, Greece
| | - Christina Kalogeropoulou
- Department of Radiology (Andreas Karatzas, Christina Kalogeropoulou), University Hospital of Patras, Patras, Greece
| | - Christos Triantos
- Department of Gastroenterology (Maria Kalafateli, Georgios Tsiaoussis, Efstratios Koutroubakis, Paraskevi Tselekouni, Nikolaos Koukias, Christos Konstantakis, Konstantinos Thomopoulos, Christos Triantos), University Hospital of Patras, Patras, Greece
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Lucidi C, Lattanzi B, Di Gregorio V, Incicco S, D'Ambrosio D, Venditti M, Riggio O, Merli M. A low muscle mass increases mortality in compensated cirrhotic patients with sepsis. Liver Int 2018; 38:851-857. [PMID: 29323441 DOI: 10.1111/liv.13691] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/28/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Severe infections and muscle wasting are both associated to poor outcome in cirrhosis. A possible synergic effect of these two entities in cirrhotic patients has not been previously investigated. We aimed at analysing if a low muscle mass may deteriorate the outcome of cirrhotic patients with sepsis. METHODS Consecutive cirrhotic patients hospitalized for sepsis were enrolled in the study. Patients were classified for the severity of liver impairment (Child-Pugh class) and for the presence of "low muscle mass" (mid-arm muscle circumference<5th percentile). The development of complication during hospitalization and survival was analysed. RESULTS There were 74 consecutive cirrhotics with sepsis. Forty-three of these patients showed low muscle mass. In patients with and without low muscle mass, severity of liver disease and characteristics of infections were similar. Mortality tended to be higher in patients with low muscle mass (47% vs 26%, P = .06). A multivariate analysis selected low muscle mass (P < .01, HR: 3.2, IC: 1.4-4.8) and Child-Pugh C (P < .01, HR: 3.3, 95% IC: 1.5-4.9) as independent predictors of in-hospital mortality. In Child-Pugh A-B patients, mortality was higher in patients with low muscle mass compared with those without (50% vs 16%; P = .01). The mortality rate and the incidence of complications in malnourished patients classified in Child-Pugh A-B were similar to those Child-Pugh C. CONCLUSIONS Low muscle mass worsen prognosis in cirrhotic patients with severe infections. This is particularly evident in patients with Child A-B cirrhosis in whom the coexistence of low muscle mass and sepsis caused a negative impact on mortality similar to that observable in all Child C patients with sepsis.
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Affiliation(s)
- Cristina Lucidi
- Gastroenterology and Hepatology Unit, Department of Clinical Medicine, La Sapienza University of Rome, Rome, Italy
| | - Barbara Lattanzi
- Gastroenterology and Hepatology Unit, Department of Clinical Medicine, La Sapienza University of Rome, Rome, Italy
| | - Vincenza Di Gregorio
- Gastroenterology and Hepatology Unit, Department of Clinical Medicine, La Sapienza University of Rome, Rome, Italy
| | - Simone Incicco
- Gastroenterology and Hepatology Unit, Department of Clinical Medicine, La Sapienza University of Rome, Rome, Italy
| | - Daria D'Ambrosio
- Gastroenterology and Hepatology Unit, Department of Clinical Medicine, La Sapienza University of Rome, Rome, Italy
| | - Mario Venditti
- Department of Infectious Disease, La Sapienza University of Rome, Rome, Italy
| | - Oliviero Riggio
- Gastroenterology and Hepatology Unit, Department of Clinical Medicine, La Sapienza University of Rome, Rome, Italy
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Department of Clinical Medicine, La Sapienza University of Rome, Rome, Italy
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25
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Dhaliwal A, Towey J, Haydon G, Elsharkawy AM, Armstrong MJ. Balancing exercise-induced weight loss with protein caloric requirement remains a challenge in overweight patients with cirrhosis. Hepatology 2018; 67:1644-1645. [PMID: 29357107 DOI: 10.1002/hep.29801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 11/26/2017] [Indexed: 12/07/2022]
Affiliation(s)
- Amritpal Dhaliwal
- Institute of Inflammation and Ageing, NIHR Birmingham Biomedical Research Centre University of Birmingham, Birmingham, UK.,Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Jenny Towey
- Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Geoffrey Haydon
- Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Ahmed M Elsharkawy
- Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Matthew J Armstrong
- Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,NIHR Birmingham Biomedical Research, Centre and Centre for Liver Research University of Birmingham, Birmingham, UK
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26
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Trivedi HD, Tapper EB. Interventions to improve physical function and prevent adverse events in cirrhosis. Gastroenterol Rep (Oxf) 2018; 6:13-20. [PMID: 29479438 PMCID: PMC5806401 DOI: 10.1093/gastro/gox042] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 11/26/2017] [Accepted: 12/01/2017] [Indexed: 12/12/2022] Open
Abstract
Cirrhosis is associated with debilitating complications that significantly impact on a patient’s physical function and reduce quality of life. Owing to highly prevalent sarcopenia, malnutrition and hepatic encephalopathy, functional impairment or frailty is a common complication of cirrhosis. Frailty in turn increases the patient’s risk of hospitalization, accidental falls and fractures, and death. The management of frailty and its associated adverse effects is imperative in improving the overall prognosis of patients with advanced liver disease. The cornerstone of therapy revolves around optimizing physical function with appropriate nutrition and exercise. Nutritional therapy with protein supplementation has shown significant benefit, while studies on exercise have been controversial. However, newly emerging studies trend towards a beneficial effect of physical exercise with improvement in quality of life. The implementation of technology in liver disease management shows future promise. Fitbits and other wearable devices can be used to help monitor a patient’s personal progress in physical exercise and nutritional optimization. Additionally, the progressive development of new smartphone applications to help aid in the diagnosis and monitoring of complications of cirrhosis provides a sophisticated avenue for improving care of patients with cirrhosis.
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Affiliation(s)
- Hirsh D Trivedi
- Liver Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Elliot B Tapper
- Department of Hepatology, University of Michigan, Ann Arbor, MI, USA
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27
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Giusto M, Barberi L, Di Sario F, Rizzuto E, Nicoletti C, Ascenzi F, Renzi A, Caporaso N, D'Argenio G, Gaudio E, Musarò A, Merli M. Skeletal muscle myopenia in mice model of bile duct ligation and carbon tetrachloride-induced liver cirrhosis. Physiol Rep 2017; 5:5/7/e13153. [PMID: 28364027 PMCID: PMC5392502 DOI: 10.14814/phy2.13153] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 01/07/2017] [Accepted: 01/17/2017] [Indexed: 12/27/2022] Open
Abstract
Skeletal muscle myopathy is universal in cirrhotic patients, however, little is known about the main mechanisms involved. The study aims to investigate skeletal muscle morphological, histological, and functional modifications in experimental models of cirrhosis and the principal molecular pathways responsible for skeletal muscle myopathy. Cirrhosis was induced by bile duct ligation (BDL) and carbon tetrachloride (CCl4) administration in mice. Control animals (CTR) underwent bile duct exposure or vehicle administration only. At sacrifice, peripheral muscles were dissected and weighed. Contractile properties of extensor digitorum longus (EDL) were studied in vitro. Muscle samples were used for histological and molecular analysis. Quadriceps muscle histology revealed a significant reduction in cross-sectional area of muscle and muscle fibers in cirrhotic mice with respect to CTR. Kinetic properties of EDL in both BDL and CCl4 were reduced with respect to CTR; BDL mice also showed a reduction in muscle force and a decrease in the resistance to fatigue. Increase in myostatin expression associated with a decrease in AKT-mTOR expressions was observed in BDL mice, together with an increase in LC3 protein levels. Upregulation of the proinflammatory citochines TNF-a and IL6 and an increased expression of NF-kB and MuRF-1 were observed in CCl4 mice. In conclusion, skeletal muscle myopenia was present in experimental models of BDL and CCl4-induced cirrhosis. Moreover, reduction in protein synthesis and activation of protein degradation were the main mechanisms responsible for myopenia in BDL mice, while activation of ubiquitin-pathway through inflammatory cytokines seems to be the main potential mechanism involved in CCl4 mice.
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Affiliation(s)
- Michela Giusto
- Gastroenterology Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Laura Barberi
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics -Unit of Histology and Medical Embryology, Sapienza University of Rome Laboratory affiliated to Istituto Pasteur Italia - Fondazione Cenci Bolognetti Rome, Italy
| | - Francesca Di Sario
- Gastroenterology Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Emanuele Rizzuto
- Department of Mechanical and Aerospace Engineering, Sapienza University of Rome, Rome, Italy
| | - Carmine Nicoletti
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics -Unit of Histology and Medical Embryology, Sapienza University of Rome Laboratory affiliated to Istituto Pasteur Italia - Fondazione Cenci Bolognetti Rome, Italy
| | - Francesca Ascenzi
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics -Unit of Histology and Medical Embryology, Sapienza University of Rome Laboratory affiliated to Istituto Pasteur Italia - Fondazione Cenci Bolognetti Rome, Italy
| | - Anastasia Renzi
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University of Rome, Rome, Italy
| | - Nicola Caporaso
- Department of Clinical and Experimental Medicine, Federico II University of Naples, Naples, Italy
| | - Giuseppe D'Argenio
- Department of Clinical and Experimental Medicine, Federico II University of Naples, Naples, Italy
| | - Eugenio Gaudio
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University of Rome, Rome, Italy
| | - Antonio Musarò
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics -Unit of Histology and Medical Embryology, Sapienza University of Rome Laboratory affiliated to Istituto Pasteur Italia - Fondazione Cenci Bolognetti Rome, Italy
| | - Manuela Merli
- Gastroenterology Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
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28
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Walcott-Sapp S, Billingsley KG. Preoperative optimization for major hepatic resection. Langenbecks Arch Surg 2017; 403:23-35. [PMID: 29150719 DOI: 10.1007/s00423-017-1638-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 11/06/2017] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Sarah Walcott-Sapp
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Mail Code: L223, Portland, OR, 97239, USA.
| | - Kevin G Billingsley
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Mail Code: L223, Portland, OR, 97239, USA
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Kim G, Kang SH, Kim MY, Baik SK. Prognostic value of sarcopenia in patients with liver cirrhosis: A systematic review and meta-analysis. PLoS One 2017; 12:e0186990. [PMID: 29065187 PMCID: PMC5655454 DOI: 10.1371/journal.pone.0186990] [Citation(s) in RCA: 214] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 10/11/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Sarcopenia is a common syndrome in chronic diseases such as liver cirrhosis. The association between sarcopenia and outcomes, such as complications and survival has recently been described in various patient groups. However, study results remain inconclusive. Therefore, the aim of this study was to systematically review the impact of sarcopenia on outcome in patients with cirrhosis. METHODS AND FINDINGS We conducted a systematic review (SR) and meta-analysis (MA) on the impact of sarcopenia on outcome in liver cirrhosis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Of the 312 studies identified, 20 were eligible according to our inclusion criteria. Most of the studies used CT to diagnose sarcopenia. Two studies used bioelectrical impedance analysis (BIA), 10 studies used skeletal muscle index (SMI) and 8 studies used total psoas muscle area (TPA). Seven studies included Asian participants and the remaining 13 studies included Western participants. The prevalence rate of sarcopenia among participants was mean 48.1%, and appeared more among men with a rate of 61.6% whereas the rate was 36% for women. With respect to clinical outcomes, patients with sarcopenia had poorer survival rates and an increased risk of complications such as infection compared to those without sarcopenia. According to the analysis of race subgroup, Asians had a HR 2.45 (95% confidence interval (CI) = 1.44-4.16, P = 0.001) of mortality whereas Westerners had a HR 1.45 (95% CI = 1.002-2.09, P<0.05). CONCLUSIONS Based on this SR and MA, the presence of sarcopenia is related to a poor prognosis and occurrence of cirrhotic complications and could be used for risk assessment. Moreover, Asian participants had higher mortality related to sarcopenia compared to the Western participants.
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Affiliation(s)
- Gaeun Kim
- Department of Nursing, Keimyung University, Daegu, Republic of Korea
| | - Seong Hee Kang
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
- * E-mail: (SHK); (SKB)
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
- Institute of Evidence based Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
- Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
- Institute of Evidence based Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
- * E-mail: (SHK); (SKB)
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30
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Hammad A, Kaido T, Aliyev V, Mandato C, Uemoto S. Nutritional Therapy in Liver Transplantation. Nutrients 2017; 9:E1126. [PMID: 29035319 PMCID: PMC5691742 DOI: 10.3390/nu9101126] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/10/2017] [Accepted: 10/12/2017] [Indexed: 12/11/2022] Open
Abstract
Protein-energy malnourishment is commonly encountered in patients with end-stage liver disease who undergo liver transplantation. Malnutrition may further increase morbidity, mortality and costs in the post-transplantation setting. The importance of carefully assessing the nutritional status during the work-up of patients who are candidates for liver replacement is widely recognized. The metabolic abnormalities induced by liver failure render the conventional assessment of nutritional status to be challenging. Preoperative loss of skeletal muscle mass, namely, sarcopenia, has a significant detrimental impact on post-transplant outcomes. It is essential to provide sufficient nutritional support during all phases of liver transplantation. Oral nutrition is preferred, but tube enteral nutrition may be required to provide the needed energy intake. Herein, the latest currently employed perioperative nutritional interventions in liver transplant recipients are thoroughly illustrated including synbiotics, micronutrients, branched-chain amino acid supplementation, immunonutrition formulas, fluid and electrolyte balance, the offering of nocturnal meals, dietary counselling, exercise and rehabilitation.
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Affiliation(s)
- Ahmed Hammad
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan.
- Department of General Surgery, Mansoura University, Mansoura 35516, Egypt.
| | - Toshimi Kaido
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan.
| | - Vusal Aliyev
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan.
| | - Claudia Mandato
- L'AORN Children's Hospital Santobono and Pausilipon, Napoli 80122, Italy.
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan.
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Low skeletal muscle mass predicts early mortality in cirrhotic patients with acute variceal bleeding. Nutrition 2017; 42:87-91. [DOI: 10.1016/j.nut.2017.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/04/2017] [Accepted: 06/17/2017] [Indexed: 12/12/2022]
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Nutritional status using subjective global assessment independently predicts outcome of patients waiting for living donor liver transplant. Indian J Gastroenterol 2017; 36:275-281. [PMID: 28856568 DOI: 10.1007/s12664-017-0779-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/22/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Malnutrition is an important risk factor for adverse outcomes in patients awaiting liver transplant. Living donor liver transplant, being an elective procedure, allows nutritional rehabilitation and optimization of these patients before transplant. AIM This paper aimed to evaluate the outcome of end-stage liver disease (ESLD) patients with various degrees of malnutrition waiting for living donor liver transplant. METHODS Nutritional status was assessed using subjective global assessment (SGA) in patients who were evaluated for a liver transplant at our center from January 2015 to September 2015. All the data were collected prospectively. Predictive factors for mortality were analyzed using logistic regression and survival was obtained using Kaplan-Meier curves. RESULTS One hundred and seventeen patients were grouped based on their nutrition status into normal, mild-moderate, and severe malnutrition. The groups were comparable in terms of age, sex, etiology of liver disease except alcoholic liver disease. Graft recipient weight ratio was comparable among groups. There was no significant difference in hospital stay. However, severe malnourished patients had higher incidence of sepsis (p=0.005) and death due to sepsis (p=0.01). Nutritional status was the only independent predictor of mortality on multivariate analysis. CONCLUSION Nutritional status measured with SGA independently predicts short-term outcome of ESLD patients waiting and after living donor liver transplant.
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Buechler C, Haberl EM, Rein-Fischboeck L, Aslanidis C. Adipokines in Liver Cirrhosis. Int J Mol Sci 2017; 18:E1392. [PMID: 28661458 PMCID: PMC5535885 DOI: 10.3390/ijms18071392] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 06/23/2017] [Accepted: 06/27/2017] [Indexed: 12/12/2022] Open
Abstract
Liver fibrosis can progress to cirrhosis, which is considered a serious disease. The Child-Pugh score and the model of end-stage liver disease score have been established to assess residual liver function in patients with liver cirrhosis. The development of portal hypertension contributes to ascites, variceal bleeding and further complications in these patients. A transjugular intrahepatic portosystemic shunt (TIPS) is used to lower portal pressure, which represents a major improvement in the treatment of patients. Adipokines are proteins released from adipose tissue and modulate hepatic fibrogenesis. These proteins affect various biological processes that are involved in liver function, including angiogenesis, vasodilation, inflammation and deposition of extracellular matrix proteins. The best studied adipokines are adiponectin and leptin. Adiponectin protects against hepatic inflammation and fibrogenesis, and leptin functions as a profibrogenic factor. These and other adipokines are supposed to modulate disease severity in patients with liver cirrhosis. Consequently, circulating levels of these proteins have been analyzed to identify associations with parameters of hepatic function, portal hypertension and its associated complications in patients with liver cirrhosis. This review article briefly addresses the role of adipokines in hepatitis and liver fibrosis. Here, studies having analyzed these proteins in systemic blood in cirrhotic patients are listed to identify adipokines that are comparably changed in the different cohorts of patients with liver cirrhosis. Some studies measured these proteins in systemic, hepatic and portal vein blood or after TIPS to specify the tissues contributing to circulating levels of these proteins and the effect of portal hypertension, respectively.
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Affiliation(s)
- Christa Buechler
- Department of Internal Medicine I, University Hospital Regensburg, 93042 Regensburg, Germany.
| | - Elisabeth M Haberl
- Department of Internal Medicine I, University Hospital Regensburg, 93042 Regensburg, Germany.
| | - Lisa Rein-Fischboeck
- Department of Internal Medicine I, University Hospital Regensburg, 93042 Regensburg, Germany.
| | - Charalampos Aslanidis
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, 93042 Regensburg, Germany.
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Carcinome hépatocellulaire : quels soins de confort ? ONCOLOGIE 2017. [DOI: 10.1007/s10269-017-2714-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Belarmino G, Gonzalez MC, Sala P, Torrinhas RS, Andraus W, D’Albuquerque LAC, Pereira RMR, Caparbo VF, Ferrioli E, Pfrimer K, Damiani L, Heymsfield SB, Waitzberg DL. Diagnosing Sarcopenia in Male Patients With Cirrhosis by Dual-Energy X-Ray Absorptiometry Estimates of Appendicular Skeletal Muscle Mass. JPEN J Parenter Enteral Nutr 2017; 42:24-36. [DOI: 10.1177/0148607117701400] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 02/21/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Giliane Belarmino
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Maria Cristina Gonzalez
- Postgraduate Program in Health and Behavior, Universidade Católica de Pelotas, Rio Grande do Sul, Brazil
- Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Priscila Sala
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Raquel Susana Torrinhas
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Wellington Andraus
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Rosa Maria R. Pereira
- Laboratory of Bone Metabolism, Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Valéria F. Caparbo
- Laboratory of Bone Metabolism, Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Ferrioli
- Department of Medical Clinic, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, São Paulo, Brazil
| | - Karina Pfrimer
- Department of Medical Clinic, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, São Paulo, Brazil
| | - Lucas Damiani
- Research Institute, Hospital do Coração de São Paulo, São Paulo, Brazil
| | | | - Dan L. Waitzberg
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Periprocedural management of acute variceal bleeding. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Bosoi CR, Oliveira MM, Ochoa-Sanchez R, Tremblay M, Ten Have GA, Deutz NE, Rose CF, Bemeur C. The bile duct ligated rat: A relevant model to study muscle mass loss in cirrhosis. Metab Brain Dis 2017; 32:513-518. [PMID: 27981407 DOI: 10.1007/s11011-016-9937-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 11/30/2016] [Indexed: 02/07/2023]
Abstract
Muscle mass loss and hepatic encephalopathy (complex neuropsychiatric disorder) are serious complications of chronic liver disease (cirrhosis) which impact negatively on clinical outcome and quality of life and increase mortality. Liver disease leads to hyperammonemia and ammonia toxicity is believed to play a major role in the pathogenesis of hepatic encephalopathy. However, the effects of ammonia are not brain-specific and therefore may also affect other organs and tissues including muscle. The precise pathophysiological mechanisms underlying muscle wasting in chronic liver disease remains to be elucidated. In the present study, we characterized body composition as well as muscle protein synthesis in cirrhotic rats with hepatic encephalopathy using the 6-week bile duct ligation (BDL) model which recapitulates the main features of cirrhosis. Compared to sham-operated control animals, BDL rats display significant decreased gain in body weight, altered body composition, decreased gastrocnemius muscle mass and circumference as well as altered muscle morphology. Muscle protein synthesis was also significantly reduced in BDL rats compared to control animals. These findings demonstrate that the 6-week BDL experimental rat is a relevant model to study liver disease-induced muscle mass loss.
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Affiliation(s)
- Cristina R Bosoi
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Mariana M Oliveira
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | | | - Mélanie Tremblay
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Gabriella A Ten Have
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, College Station, TX, USA
| | - Nicolaas E Deutz
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, College Station, TX, USA
| | - Christopher F Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Chantal Bemeur
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montréal, Canada.
- Département de nutrition, Faculté de médecine, Université de Montréal, CP 6128 Succ. Centre-ville, Montréal, Québec, H3C 3J7, Canada.
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Scappaticci GB, Regal RE. Cockcroft-Gault revisited: New de-liver-ance on recommendations for use in cirrhosis. World J Hepatol 2017; 9:131-138. [PMID: 28217249 PMCID: PMC5295146 DOI: 10.4254/wjh.v9.i3.131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 11/11/2016] [Accepted: 12/14/2016] [Indexed: 02/06/2023] Open
Abstract
The Cockcroft-Gault (CG) equation has become perhaps the most popular practical approach for estimating renal function among health care professionals. Despite its widespread use, clinicians often overlook not only the limitations of the original serum creatinine (SCr) based equation, but also may not appreciate the validity of the many variations used to compensate for these limitations. For cirrhotic patients in particular, the underlying pathophysiology of the disease contributes to a falsely low SCr, thereby overestimating renal function with use of the CG equation in this population. We reviewed the original CG trial from 1976 along with data surrounding clinician specific alterations to the CG equation that followed through time. These alterations included different formulas for body weight in obese patients and the “rounding up” approach in patients with low SCr. Additionally, we described the pathophysiology and hemodynamic changes that occur in cirrhosis; and reviewed several studies that attempted to estimate renal function in this population. The evidence we reviewed regarding the most accurate manipulation of the original CG equation to estimate creatinine clearance (CrCl) was inconclusive. Unfortunately, the homogeneity of the patient population in the original CG trial limited its external validity. Elimination of body weight in the CG equation actually produced the estimate closest to the measure CrCl. Furthermore, “rounding up” of SCr values often underestimated CrCl. This approach could lead to suboptimal dosing of drug therapies in patients with low SCr. In cirrhotic patients, utilization of SCr based methods overestimated true renal function by about 50% in the literature we reviewed.
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Abstract
Zinc is an essential trace element playing fundamental roles in cellular metabolism. It acts mostly by binding a wide range of proteins, thus affecting a broad spectrum of biological processes, which include cell division, growth and differentiation. Zinc is critical to a large number of structural proteins, enzymatic processes, and transcription factors. Zinc deficiency can result in a spectrum of clinical manifestations, such as poor of appetite, loss of body hair, altered taste and smell, testicular atrophy, cerebral and immune dysfunction, and diminished drug elimination capacity. These are common symptoms in patients with chronic liver diseases, especially liver cirrhosis. The liver is the main organ responsible for the zinc metabolism which can be affected by liver diseases. On the other hand, zinc deficiency may alter hepatocyte functions and also immune responses in inflammatory liver diseases. Liver cirrhosis represents the most advanced stage of chronic liver diseases and is the common outcome of chronic liver injury. It is associated with energy malnutrition, with numerous metabolic disorders, such as hypoalbuminemia, with imbalance between branched-chain amino acids and aromatic amino acids, and with reduced zinc serum concentrations. All these processes can influence the clinical outcome of patients, such ascites, hepatic encephalopathy and hepatocellular carcinoma. In the present review, we summarize the emerging evidence on the pitoval role of zinc in the pathogenesis of liver cirrhosis.
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Affiliation(s)
| | - Dirk Reinhold
- Institute of Molecular and Clinical Immunology, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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Rachakonda V, Borhani AA, Dunn MA, Andrzejewski M, Martin K, Behari J. Serum Leptin Is a Biomarker of Malnutrition in Decompensated Cirrhosis. PLoS One 2016; 11:e0159142. [PMID: 27583675 PMCID: PMC5008824 DOI: 10.1371/journal.pone.0159142] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 06/28/2016] [Indexed: 02/07/2023] Open
Abstract
Background and Aims Malnutrition is a leading cause of morbidity and mortality in cirrhosis. There is no consensus as to the optimal approach for identifying malnutrition in end-stage liver disease. The aim of this study was to measure biochemical, serologic, hormonal, radiographic, and anthropometric features in a cohort of hospitalized cirrhotic patients to characterize biomarkers for identification of malnutrition. Design In this prospective observational cohort study, 52 hospitalized cirrhotic patients were classified as malnourished (42.3%) or nourished (57.7%) based on mid-arm muscle circumference < 23 cm and dominant handgrip strength < 30 kg. Anthropometric measurements were obtained. Appetite was assessed using the Simplified Nutrition Appetite Questionnaire (SNAQ) score. Fasting levels of serum adipokines, cytokines, and hormones were determined using Luminex assays. Logistic regression analysis was used to determine features independently associated with malnutrition. Results Subjects with and without malnutrition differed in several key features of metabolic phenotype including wet and dry BMI, skeletal muscle index, visceral fat index and HOMA-IR. Serum leptin levels were lower and INR was higher in malnourished subjects. Serum leptin was significantly correlated with HOMA-IR, wet and dry BMI, mid-arm muscle circumference, skeletal muscle index, and visceral fat index. Logistic regression analysis revealed that INR and log-transformed leptin were independently associated with malnutrition. Conclusions Low serum leptin and elevated INR are associated with malnutrition in hospitalized patients with end-stage liver disease.
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Affiliation(s)
- Vikrant Rachakonda
- Department of Medicine, Divisions of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh PA 15213, United States of America
| | - Amir A Borhani
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, United States of America
| | - Michael A Dunn
- Department of Medicine, Divisions of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh PA 15213, United States of America
| | - Margaret Andrzejewski
- Department of Medicine, Divisions of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh PA 15213, United States of America
| | - Kelly Martin
- Department of Medicine, Divisions of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh PA 15213, United States of America
| | - Jaideep Behari
- Department of Medicine, Divisions of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh PA 15213, United States of America
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Chen Y, Kintner J, Rifkin SK, Keim KS, Tangney CC. Changes in Resting Energy Expenditure Following Orthotopic Liver Transplantation. JPEN J Parenter Enteral Nutr 2016; 40:877-82. [DOI: 10.1177/0148607115586435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 04/16/2015] [Indexed: 12/24/2022]
Affiliation(s)
- Yimin Chen
- Rush University Medical Center, Chicago, Illinois, USA
| | - Jennifer Kintner
- Rush University Medical Center, Chicago, Illinois, USA
- Presbyterian Hospital, Albuquerque, New Mexico, USA
| | - Sam K. Rifkin
- Rush University Medical Center, Chicago, Illinois, USA
- Morrison Senior Living, Chicago, Illinois, USA
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Wilasco MIA, Uribe-Cruz C, Santetti D, Pfaffenseller B, Dornelles CTL, da Silveira TR. Brain-Derived Neurotrophic Factor in Children and Adolescents with Cirrhosis Due to Biliary Atresia. ANNALS OF NUTRITION AND METABOLISM 2016; 69:1-8. [PMID: 27382957 DOI: 10.1159/000447364] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 05/25/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND The nutritional status in patients with cirrhosis is not so easy to assess properly. Considering the relationship between brain-derived neurotrophic factor (BDNF) and energy homeostasis, the main aim of this study was to evaluate the concentration of BDNF in children and adolescents with cirrhosis due to biliary atresia (BA) and correlate it with their nutritional status. METHODS Fifty-three children and adolescents with cirrhosis due to BA and 33 healthy controls were enrolled in this study. Nutritional status was evaluated using anthropometric parameters, and serum BDNF was measured by ELISA. Spearman coefficient was used to evaluate the correlation between variables. RESULTS In the cirrhosis group, 28.8% were undernourished and in the control group, 100% were well-nourished. BDNF median values for the control and cirrhosis group were 28.5 and 9.0 pg/ml respectively. BDNF and platelets were positively associated with both Standard Deviation Score (SDS) for height-for-age ratio and SDS for triceps skinfold thickness-for-age ratio. CONCLUSIONS Considering these associations, BDNF may be an indirect biomarker of nutritional status in children and adolescents with chronic liver disease. Further studies must be conducted to clarify the role of BDNF in this population.
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Affiliation(s)
- Maria Inês A Wilasco
- Experimental Laboratory of Gastroenterology and Hepatology, Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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Hanai T, Shiraki M, Ohnishi S, Miyazaki T, Ideta T, Kochi T, Imai K, Suetsugu A, Takai K, Moriwaki H, Shimizu M. Rapid skeletal muscle wasting predicts worse survival in patients with liver cirrhosis. Hepatol Res 2016; 46:743-51. [PMID: 26579878 DOI: 10.1111/hepr.12616] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/23/2015] [Accepted: 10/30/2015] [Indexed: 02/08/2023]
Abstract
AIM Sarcopenia impairs the outcome of patients with liver cirrhosis independently of liver function reserves. The aim of this study was to investigate whether the rate of skeletal muscle wasting predicts mortality in cirrhotic patients. METHODS This retrospective study evaluated 149 cirrhotic patients who visited our hospital between March 2004 and September 2012. The skeletal muscle cross-sectional area at the level of the third lumbar vertebra was measured by computed tomography, from which the skeletal muscle index was obtained for diagnosis of sarcopenia. The relative change in skeletal muscle area per year (ΔSMA/y) was calculated in each patient. Cox proportional hazards regression analysis was performed to evaluate risk factors for mortality. RESULTS Of the 149 cirrhotic patients, 94 (63%) were diagnosed with sarcopenia. The median of ΔSMA/y in all patients was -2.2%. For patients in Child-Pugh class A, B and C, ΔSMA/y was -1.3%, -3.5% and -6.1%, respectively. During a median follow-up period of 39 months (range, 1-110), 45 patients (30%) died. The optimal cut-off value of ΔSMA/y for predicting mortality was -3.1%; the survival rate in patients with ΔSMA/y of -3.1% or less was significantly lower than in patients with ΔSMA/y of more than -3.1% (P < 0.0001). The multivariate Cox proportional hazards model found ΔSMA/y of -3.1% or less to be significantly associated with mortality in cirrhotic patients (hazard ratio = 2.73, 95% confidence interval = 1.43-5.44, P < 0.01). CONCLUSION ΔSMA/y is useful for predicting mortality in patients with liver cirrhosis. Management of skeletal muscle may contribute toward improving the outcome of cirrhotic patients.
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Affiliation(s)
- Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Makoto Shiraki
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Sachiyo Ohnishi
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Tsuneyuki Miyazaki
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takayasu Ideta
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takahiro Kochi
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kenji Imai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Atsushi Suetsugu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Koji Takai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.,Division for Regional Cancer Control, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hisataka Moriwaki
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
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GUERRA TS, HOEHR NF, BOIN IDFSF, STUCCHI RSB. TRACE ELEMENTS IN PLASMA AND NUTRITIONAL ASSESSMENT IN PATIENTS WITH COMPENSATED CIRRHOSIS ON A LIVER TRANSPLANT LIST. ARQUIVOS DE GASTROENTEROLOGIA 2016; 53:84-8. [DOI: 10.1590/s0004-28032016000200006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/18/2016] [Indexed: 12/13/2022]
Abstract
ABSTRACT Background - In chronic liver disease, trace element levels in plasma are usually low. However, the specific cause and functional implications of this abnormality are yet not well understood. These element levels may decrease as a result of abnormal liver function in patients with cirrhosis and/or malnutrition. Objective - To evaluate the nutritional status and the profile of trace elements in plasma of patients with cirrhosis on a liver transplant list and to correlate them with disease severity. Methods - This cross-sectional study evaluated 31 male patients diagnosed with compensated liver cirrhosis on a waiting list for liver transplant. Nutritional status was objectively evaluated through anthropometry using Mendenhall score and Blackburn classification, subjectively through the Detsky questionnaire and severity of the disease by MELD and CTP score. Trace elements (Zn, Se, Cu, Ca, Fe, Mg and Mn) in plasma were analyzed by inductively coupled plasma mass spectrometry (ICP-MS). Statistical analysis was performed using Mann-Whitney test. Results - According to the nutritional assessment 19 (61.3%) were malnourished and 12 (38.7%) were overweight. Regarding disease severity 12 (39%) were classified as Child A, 17 (55%), Child B and 2 (6%) Child C, with 46.9% of patients with MELD score >17. The trace element analysis indicated that 31 (100%) had Mn levels above the reference range, 23 (74.2%) low levels of Cu, 29 (93.5%) with deficiency of Se, and 31 (100%) low levels of Ca and Mg. Disease severity did not show statistical difference between the studied trace elements, in contrast to the nutritional status, in which the malnourished group showed higher levels of Mn (P=0.01) and Fe (P=0.01) and low levels of Zn (P=0.03) when compared to the overweight group. Conclusion - The results showed that the trace elements in plasma are altered in chronic liver disease; without significant correlation to disease severity, but correlated to nutritional status. Malnutrition is present in the patients studied, nonetheless a new scenario with an increase in the prevalence of overweight was verified regardless of the degree of hepatic decompensation.
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Montano-Loza AJ, Angulo P, Meza-Junco J, Prado CMM, Sawyer MB, Beaumont C, Esfandiari N, Ma M, Baracos VE. Sarcopenic obesity and myosteatosis are associated with higher mortality in patients with cirrhosis. J Cachexia Sarcopenia Muscle 2016; 7:126-35. [PMID: 27493866 PMCID: PMC4864157 DOI: 10.1002/jcsm.12039] [Citation(s) in RCA: 356] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/16/2015] [Accepted: 04/09/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND AIMS Obesity is frequently associated with cirrhosis, and cirrhotic patients may develop simultaneous loss of skeletal muscle and gain of adipose tissue, culminating in the condition of sarcopenic obesity. Additionally, muscle depletion is characterized by both a reduction in muscle size and increased proportion of muscular fat, termed myosteatosis. In this study, we aimed to establish the frequency and clinical significance of sarcopenia, sarcopenic obesity and myosteatosis in cirrhotic patients. METHODS We analysed 678 patients with cirrhosis. Sarcopenia, sarcopenic obesity and myosteatosis were analysed by CT scan using the third lumbar vertebrae skeletal muscle and attenuation indexes, using previously validated gender-and body mass index-specific cutoffs. RESULTS Patients were predominately men (n = 457, 67%), and cirrhosis aetiology was hepatitis C virus in 269 patients (40%), alcohol in 153 (23%), non-alcoholic steatohepatitis/cryptogenic in 96 (14%), autoimmune liver disease in 55 (8%), hepatitis B virus in 43 (6%), and others in 5 patients (1%). Sarcopenia was present in 292 (43%), 135 had sarcopenic obesity (20%) and 353 had myosteatosis (52%). Patients with sarcopenia (22 ± 3 vs. 95 ± 22 months, P < 0.001), sarcopenic obesity (22 ± 3 vs. 95 ± 22 months, P < 0.001), and myosteatosis (28 ± 5 vs. 95 ± 22 months, P < 0.001) had worse median survival than patients without muscular abnormalities. By multivariate Cox regression analysis, both sarcopenia [hazard ratio (HR) 2.00, 95% confidence interval (CI) 1.44-2.77, P < 0.001], and myosteatosis (HR 1.42, 95% CI 1.02-1.07, P = 0.04) were associated with mortality. CONCLUSIONS Sarcopenia, sarcopenic obesity and myosteatosis are often present in patients with cirrhosis, and sarcopenia and myosteatosis are independently associated with a higher long-term mortality in cirrhosis.
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Affiliation(s)
- Aldo J Montano-Loza
- Division of Gastroenterology & Liver Unit University of Alberta Hospital Edmonton Alberta Canada
| | - Paul Angulo
- Division of Digestive Diseases & Nutrition University of Kentucky Medical Center Lexington KY USA
| | - Judith Meza-Junco
- Department of Oncology Cross Cancer Institute Edmonton Alberta Canada
| | - Carla M M Prado
- Department of Agricultural Food and Nutritional Sciences Edmonton Alberta Canada
| | - Michael B Sawyer
- Department of Oncology Cross Cancer Institute Edmonton Alberta Canada
| | - Crystal Beaumont
- Department of Oncology Cross Cancer Institute Edmonton Alberta Canada
| | - Nina Esfandiari
- Department of Oncology Cross Cancer Institute Edmonton Alberta Canada
| | - Mang Ma
- Division of Gastroenterology & Liver Unit University of Alberta Hospital Edmonton Alberta Canada
| | - Vickie E Baracos
- Department of Oncology Cross Cancer Institute Edmonton Alberta Canada
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Abstract
OPINION STATEMENT Most widely recognized complications in cirrhotic patients include ascites, hepatic encephalopathy, variceal bleeding, kidney dysfunction, and hepatocellular carcinoma; however, malnutrition and muscle wasting (sarcopenia) constitute common complications which negatively impact survival, quality of life, and response to stressors, such as infection and surgery in patients with cirrhosis. Despite the important role that malnutrition and sarcopenia play in the prognosis of patients with cirrhosis, they are frequently overlooked, in part because nutritional assessment can be a difficult task in patients with cirrhosis due to fluid retention and/or overweight. Moreover, patients with cirrhosis may develop simultaneous loss of skeletal muscle and gain of adipose tissue, culminating in the condition of "sarcopenic obesity." In addition, muscle depletion is characterized by both a reduction in muscle size and increased proportion of intermuscular and intramuscular fat-denominated "myosteatosis." Sarcopenia in cirrhotic patients has been associated with increased mortality, sepsis complications, hyperammonemia, overt hepatic encephalopathy, and increased length of stay after liver transplantation. Muscularity assessment with cross-sectional imaging studies has become an attractive index of nutritional status evaluation in cirrhosis, as sarcopenia reflects a chronic detriment in general physical condition, rather than acute severity of the liver disease. In this review, we discuss the current diagnostic methods to evaluate malnutrition and muscle abnormalities in cirrhosis and also analyze the current knowledge regarding incidence and clinical impact of malnutrition and muscle abnormalities in cirrhosis and their impact after liver transplantation. We also discuss existing and potential novel therapeutic strategies for malnutrition in cirrhosis, emphasizing the recognition of sarcopenia in cirrhosis in an effort to improve survival and reduce morbidity related to cirrhosis. Finally, we analyze new studies including sarcopenia with the MELD score that seems to allow better prediction of mortality among cirrhotic patients waiting for liver transplantation.
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Affiliation(s)
- Ragesh B Thandassery
- From the Division of Gastroenterology and Liver Unit, University of Alberta Hospital, Zeidler Ledcor Centre, 130 University Campus, Edmonton, AB, T6G 2X8, Canada
| | - Aldo J Montano-Loza
- From the Division of Gastroenterology and Liver Unit, University of Alberta Hospital, Zeidler Ledcor Centre, 130 University Campus, Edmonton, AB, T6G 2X8, Canada.
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Prieto-Frías C, Conchillo M, Payeras M, Iñarrairaegui M, Davola D, Frühbeck G, Salvador J, Rodríguez M, Richter JÁ, Mugueta C, Gil MJ, Herrero I, Prieto J, Sangro B, Quiroga J. Factors related to increased resting energy expenditure in men with liver cirrhosis. Eur J Gastroenterol Hepatol 2016; 28:139-45. [PMID: 26560751 DOI: 10.1097/meg.0000000000000516] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- César Prieto-Frías
- aDepartment of Gastroenterology bLiver Unit, Department of Medicine cDepartment of Endocrinology dDepartment of Nuclear Medicine eDepartment of Laboratory Medicine, Clínica Universidad de Navarra fInstitute for Biomedical Research in Navarra (IDISNA), Pamplona gBiomedical Research Network in Liver and Digestive Diseases (CIBEREHD), Madrid, Spain
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Vidot H, Teevan K, Carey S, Strasser S, Shackel N. A prospective audit of preprocedural fasting practices on a transplant ward: when fasting becomes starving. J Clin Nurs 2016; 25:829-35. [DOI: 10.1111/jocn.13116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2015] [Indexed: 12/24/2022]
Affiliation(s)
- Helen Vidot
- Liver Disease and Transplantation; Department Nutrition & Dietetics; Royal Prince Alfred Hospital; Camperdown NSW Australia
- Centenary Institute; Camperdown NSW Australia
| | - Kate Teevan
- Hepatitis C; AW Morrow Gastroenterology and Liver Centre; Royal Prince Alfred Hospital; Camperdown NSW Australia
| | - Sharon Carey
- Nutrition & Dietetics; Royal Prince Alfred Hospital; Camperdown NSW Australia
| | - Simone Strasser
- Central Clinical School (Medicine); University of Sydney; Camperdown NSW Australia
- AW Morrow Gastroenterology and Liver Centre; Royal Prince Alfred Hospital; Camperdown NSW Australia
| | - Nicholas Shackel
- AW Morrow Gastroenterology and Liver Centre; Royal Prince Alfred Hospital; Camperdown NSW Australia
- Centenary Institute; Newtown NSW Australia
- Faculty of Medicine; University of Sydney; Camperdown NSW Australia
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49
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Lin WY, Peng CY, Lin CC, Davidson LE, Pi-Sunyer FX, Sung PK, Huang KC. General and Abdominal Adiposity and Risk of Death in HBV Versus Non-HBV Carriers: A 10-Year Population-based Cohort Study. Medicine (Baltimore) 2016; 95:e2162. [PMID: 26765398 PMCID: PMC4718224 DOI: 10.1097/md.0000000000002162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 10/31/2015] [Accepted: 11/04/2015] [Indexed: 12/13/2022] Open
Abstract
Both obesity and hepatitis B virus (HBV) infection increase the risk of death. We investigate the association between general and central obesity and all-cause mortality among adult Taiwanese HBV versus non-HBV carriers.A total of 19,850 HBV carriers and non-hepatitis C virus (HCV) carriers, aged 20 years and older at enrollment in 1998 to 1999 in Taiwan, were matched to 79,400 non-HBV and non-HCV carriers (1:4). Cox proportional-hazards models were used to estimate the relative risks for all-cause mortality during a maximum follow-up period of 10 years. Four obesity-related anthropometric indices-body mass index (BMI), waist circumference, waist-to-hip ratio, and waist-to-height ratio-were the main variables of interest.During the follow-up period, 628 and 2366 participants died among HBV and non-HBV carriers, respectively. Both underweight and general obesity were associated with an increased risk of death. The highest risk of all-cause death in relation to BMI was found in the HBV carriers with underweight (BMI <18.5 kg/m2) and non-HBV carriers with obesity (BMI ≥30 kg/m2). The lowest risks of all-cause death in relation to abdominal adiposity were found at the third quartiles of waist circumference, waist-to-hip ratio, and waist-to-height ratio among HBV carriers, but in the second quartiles among non-HBV carriers. For those with pre-existing liver disease among HBV carriers, patients with underweight have higher risk of death than those with obesity.Hepatitis B virus carriers with underweight have higher risk of death than non-HBV carriers. HBV carriers with mild abdominal obesity have the lowest risk of death, but not in the non-HBV carriers.
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Affiliation(s)
- Wen-Yuan Lin
- From the Department of Family Medicine (W-YL, C-CL); Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan (C-YP); School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan(W-YL, C-CL, C-YP); Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan (W-YL, K-CH); Institute of Health Care Administration, College of Health Science, Asia University, Taichung, Taiwan (C-CL); MJ Health Screening Center, Taipei, Taiwan (P-KS); College of Life Sciences, Brigham Young University, Utah, USA (LED); and New York Presbyterian Hospital, Columbia University, New York, USA (FXP-S)
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50
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Pérez-Reyes E, Rivera-Sánchez J, Servín-Caamaño A, Pérez-Torres E, Abdo-Francis J, Higuera-de la Tijera F. Malnutrition is related to a higher frequency of serious complications in patients with cirrhosis. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2016. [DOI: 10.1016/j.hgmx.2015.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
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