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Bergaoui J, Latiri I, Chaouch H, Ben Abdallah J, Mrad S, Maatamri W, Letaief A, Ben Saad H. Evaluation of muscle strength and quality in North African patients with chronic hepatitis B: A pilot case control study. Libyan J Med 2023; 18:2204564. [PMID: 37096573 PMCID: PMC10132249 DOI: 10.1080/19932820.2023.2204564] [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: 04/26/2023] Open
Abstract
Early detection of alteration of muscle strength, quantity, and quality, and sarcopenia is useful in non-cirrhotic chronic hepatitis B (NC-CHB) patients. Studies, which explored the handgrip strength (HGS) are scarce with questionable results, and no previous case-control study explored the presence of sarcopenia.The aim of this study was to assess the muscle strength [i.e.; HGS absolute (HGSA), HGSA/body mass index (BMI)], muscle quantity [i.e.; appendicular skeletal muscle (ASM), ASM/height2, ASM/total body weight (TBW), ASM/BMI], and muscle quality [i.e.; HGSA/total muscle mass (TMM), HGSA/ASM] of NC-CHB patients.This was a case-control study. Cases (n = 26) were untreated NC-CHB patients, and controls (n = 28) were 'apparently' healthy participants. Muscle mass was estimated via the TMM (kg) and ASM (kg). Muscle strength was evaluated via the HGS data [i.e.; HGSA (kg), HGSA/BMI (m2)]. Six variants of HGSA were determined: highest values for the dominant and non-dominant hands, highest value between the two hands, averages of the three measurements for the two hands, and the average of the highest values of the two hands. Muscle quantity was expressed in three relative variants (ASM/height2, ASM/TBW, and ASM/BMI). Muscle quality was evaluated via relative HGS data adjusted by muscle mass (i.e.; HGSA/TMM, HGSA/ASM). Probable and confirmed sarcopenia were retained in front of low muscle strength, and low muscle strength and muscle quantity or quality, respectively.There were no significant differences between controls and NC-CHB patients in values of muscle i) Strength whatever the HGS' mode of expression (e.g.; HGSA/BMI: 1.59 ± 0.54 vs. 1.53 ± 0.54 m2, p = 0.622, respectively), ii) Quantity (e.g.; ASM/BMI: 0.79 ± 0.24 vs. 0.77 ± 0.23 m2, p = 0.883), and iii) Quality (e.g.; HGSA/ASM: 2.00 ± 0.25 vs. 2.01 ± 0.41, p = 0.952, respectively). One NC-CHB participant had a confirmed sarcopenia.To conclude, both controls and NC-CHB patients had similar HGS values. Only one NC-CHB patient had a confirmed sarcopenia.
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Affiliation(s)
- Jihene Bergaoui
- Research laboratory "Heart Failure, LR12SP09", Hospital Farhat HACHED, Sousse, Tunisia
| | - Imed Latiri
- Research laboratory "Heart Failure, LR12SP09", Hospital Farhat HACHED, Sousse, Tunisia
- Faculty of Medicine of Sousse, Department of Physiology, Sousse University, Sousse, Tunisia
| | - Houda Chaouch
- Department of Infectious Diseases, Viral Hepatitis Research Unit (UR12SP35), Hospital Farhat HACHED, Sousse, Tunisia
| | - Jihene Ben Abdallah
- Biochemistry Research Laboratory (LR18ES47), Hospital Farhat HACHED, Sousse, Tunisia
| | - Sawssen Mrad
- Biochemistry Research Laboratory (LR18ES47), Hospital Farhat HACHED, Sousse, Tunisia
| | - Wided Maatamri
- Haematological laboratory, Hospital Farhat HACHED, Sousse, Tunisia
| | - Amel Letaief
- Department of Infectious Diseases, Viral Hepatitis Research Unit (UR12SP35), Hospital Farhat HACHED, Sousse, Tunisia
| | - Helmi Ben Saad
- Research laboratory "Heart Failure, LR12SP09", Hospital Farhat HACHED, Sousse, Tunisia
- Faculty of Medicine of Sousse, Department of Physiology, Sousse University, Sousse, Tunisia
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Han E, Lee YH. Lean or Non-obese Nonalcoholic Fatty Liver Disease Patients: Are They Really Lean? Clin Mol Hepatol 2023; 29:980-983. [PMID: 37584065 PMCID: PMC10577344 DOI: 10.3350/cmh.2023.0250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/11/2023] [Accepted: 08/11/2023] [Indexed: 08/17/2023] Open
Affiliation(s)
- Eugene Han
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Yong-ho Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Korea
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3
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Han E, Chun HS, Lee YH, Lee JS, Lee HW, Kim BK, Park JY, Kim DY, Lee BW, Kang ES, Cha BS, Ahn SH, Kim SU. MAFLD might be better in identifying subjects with sarcopenia or cardiovascular risk than NAFLD: A nationwide study. J Gastroenterol Hepatol 2023; 38:1598-1609. [PMID: 37321651 DOI: 10.1111/jgh.16261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 05/14/2023] [Accepted: 05/30/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND AIM Clinical features of non-alcoholic fatty liver disease (NAFLD), but not fulfilling the diagnostic criteria of metabolic dysfunction-associated fatty liver disease (MAFLD), remain unclear. We investigated the risk of sarcopenia and cardiovascular disease (CVD) in MAFLD and non-metabolic risk (MR) NAFLD. METHODS Subjects were selected from the Korean National Health and Nutrition Examination Surveys 2008-2011. Liver steatosis was assessed using fatty liver index. Significant liver fibrosis was defined using fibrosis-4 index, categorized by age cut-offs. Sarcopenia was defined as the lowest quintile sarcopenia index. Atherosclerotic CVD (ASCVD) risk score > 10% was defined as high probability. RESULTS A total of 7248 subjects had fatty liver (137 with non-MR NAFLD, 1752 with MAFLD/non-NAFLD, and 5359 with overlapping MAFLD and NAFLD). In non-MR NAFLD group 28 (20.4%) had significant fibrosis. The risk of sarcopenia (adjusted odds ratio [aOR] = 2.71, 95% confidence index [CI] = 1.27-5.78) and high probability of ASCVD (aOR = 2.79, 95% CI = 1.23-6.35) was significantly higher in MAFLD/non-NAFLD group than in non-MR NAFLD group (all P < 0.05). The risk of sarcopenia and high probability of ASCVD was similar between subjects with and without significant fibrosis in non-MR NAFLD group (all P > 0.05). However, the risk was significantly higher in MAFLD group than in non-MR NAFLD group (aOR = 3.38 for sarcopenia and 3.73 for ASCVD; all P < 0.05). CONCLUSIONS The risks of sarcopenia and CVD were significantly higher in MAFLD group but did not differ according to fibrotic burden in non-MR NAFLD group. The MAFLD criteria might be better for identifying high-risk fatty liver disease than the NAFLD criteria.
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Affiliation(s)
- Eugene Han
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, South Korea
| | - Ho Soo Chun
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, South Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong-Ho Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Seung Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Yonsei Liver Center, Severance Hospital, Seoul, South Korea
| | - Hye Won Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Yonsei Liver Center, Severance Hospital, Seoul, South Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Yonsei Liver Center, Severance Hospital, Seoul, South Korea
| | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Yonsei Liver Center, Severance Hospital, Seoul, South Korea
| | - Do Young Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Yonsei Liver Center, Severance Hospital, Seoul, South Korea
| | - Byung-Wan Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, South Korea
| | - Eun Seok Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, South Korea
| | - Bong-Soo Cha
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, South Korea
| | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Yonsei Liver Center, Severance Hospital, Seoul, South Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Yonsei Liver Center, Severance Hospital, Seoul, South Korea
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Petroff D, Wiegand J, Karlas T. Editorial: Let your muscles do the talking-what can muscle quality tell us about hepatic fibrosis? Aliment Pharmacol Ther 2023; 58:372-373. [PMID: 37452590 DOI: 10.1111/apt.17618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Affiliation(s)
- David Petroff
- Clinical Trial Centre, Leipzig University, Leipzig, Germany
| | - Johannes Wiegand
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Thomas Karlas
- Division of Gastroenterology, Department of Medicine II, University Hospital Leipzig, Leipzig, Germany
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Coelho MPP, de Castro PASV, de Vries TP, Colosimo EA, Bezerra JMT, Rocha GA, Silva LD. Sarcopenia in chronic viral hepatitis: From concept to clinical relevance. World J Hepatol 2023; 15:649-665. [PMID: 37305369 PMCID: PMC10251280 DOI: 10.4254/wjh.v15.i5.649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/17/2023] [Accepted: 04/06/2023] [Indexed: 05/24/2023] Open
Abstract
Although the frequency of metabolic risk factors for cirrhosis and hepatocellular carcinoma (HCC) is increasing, chronic hepatitis B (CHB) and chronic hepatitis C (CHC) remain the most relevant risk factors for advanced liver disease worldwide. In addition to liver damage, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are associated with a myriad of extrahepatic manifestations including mixed cryoglobulinaemia, lymphoproliferative disorders, renal disease, insulin resistance, type 2 diabetes, sicca syndrome, rheumatoid arthritis-like polyarthritis, and autoantibody production. Recently, the list has grown to include sarcopenia. Loss of muscle mass or muscle function is a critical feature of malnutrition in cirrhotic patients and has been found in approximately 23.0%-60.0% of patients with advanced liver disease. Nonetheless, among published studies, there is significant heterogeneity in the aetiologies of hepatic diseases and measurement methods used to determine sarcopenia. In particular, the interaction between sarcopenia, CHB and CHC has not been completely clarified in a real-world setting. Sarcopenia can result from a complex and multifaceted virus-host-environment interplay in individuals chronically infected with HBV or HCV. Thus, in the present review, we provide an overview of the concept, prevalence, clinical relevance, and potential mechanisms of sarcopenia in patients with chronic viral hepatitis, with an emphasis on clinical outcomes, which have been associated with skeletal muscle loss in these patients. A comprehensive overview of sarcopenia in individuals chronically infected with HBV or HCV, independent of the stage of the liver disease, will reinforce the necessity of an integrated medical/nutritional/physical education approach in the daily clinical care of patients with CHB and CHC.
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Affiliation(s)
- Marta Paula Pereira Coelho
- Sciences Applied to Adult Health Care Post-Graduate Programme, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Pedro Alves Soares Vaz de Castro
- Medical Undergraduate Student, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Thaís Pontello de Vries
- Sciences Applied to Adult Health Care Post-Graduate Programme, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Enrico Antônio Colosimo
- Department of Statistics, Instituto de Ciências Exatas, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Juliana Maria Trindade Bezerra
- Department of Biological Sciences, Universidade Estadual do Maranhão, Açailândia 65715-000, Maranhão, Brazil
- Post-Graduate Programme of Animal Science, Universidade Estadual do Maranhão, São Luiz do Maranhão 65.055-310, Maranhão, Brazil
| | - Gifone Aguiar Rocha
- Laboratory of Research in Bacteriology, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Luciana Diniz Silva
- Department of Internal Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
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Manabe T, Ogawa C, Takuma K, Nakahara M, Oura K, Tadokoro T, Fujita K, Tani J, Shibatoge M, Morishita A, Kudo M, Masaki T. Usefulness of the Measurement of Psoas Muscle Volume for Sarcopenia Diagnosis in Patients with Liver Disease. Diagnostics (Basel) 2023; 13:diagnostics13071245. [PMID: 37046463 PMCID: PMC10093033 DOI: 10.3390/diagnostics13071245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Computed tomography (CT) is often used in the diagnosis of sarcopenia. In this study, we validated the assessment of sarcopenia by the psoas muscle volume using versatile software. The study involved a retrospective analysis of data from 190 patients with liver disease who underwent grip-strength testing and abdominal pelvic computed tomography. To assess sarcopenia, SYNAPSE 3D was used to obtain the skeletal muscle index, the psoas muscle index (PMI), and the simple method. We also used the recently proposed PMI cutoff values, for which the usefulness has been evaluated (O-PMI). The cutoff value of the psoas muscle volume index (PMVI) was determined using one of the diagnostic methods as the gold standard. All diagnostic methods showed that patients with sarcopenia had shorter survival, with O-PMI having the highest hazard ratio (HR) (HR, 6.12; 95% confidence interval [CI], 2.6–14.41; p < 0.001). Even when sarcopenia could not be diagnosed by O-PMI, low PMVI was associated with shorter survival (HR, 3.53; 95% CI, 1.34–9.32; p = 0.01). PMVI may be useful in the evaluation of sarcopenia, including the identification of poor overall survival in cases that cannot be diagnosed by O-PMI, which is considered more useful than PMI.
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Wang Z, Li S, Wang K, Zhang M, Wu J, Liu D, Liang K. Association of sarcopenia with liver fibrosis and steatohepatitis in non-alcoholic fatty liver disease: protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e066181. [PMID: 36737085 PMCID: PMC9900053 DOI: 10.1136/bmjopen-2022-066181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Non-alcoholic fatty liver disease (NAFLD) has become the most common chronic liver disorder over the last four decades, more evidence shows a high prevalence of sarcopenia in NAFLD that may influence disease severity. This meta-analysis aims to determine the association of sarcopenia with liver fibrosis and steatohepatitis in NAFLD. METHODS AND ANALYSIS We will conduct the literature search using Medline (via PubMed), Web of Science databases, EMBASE, Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews (from the date of inception to 1 May 2022). There will be no restriction to the publication year. Two reviewers will independently screen the articles and abstract key study characteristics. The outcome of this meta-analysis is the strength of association of sarcopenia with liver fibrosis and steatohepatitis in NAFLD. The STATA (V.14, StataCorp, 2015) will be used to carry out the statistical analysis. Comprehensive evaluation of bias risk and heterogeneity will be performed before data synthesis. Also, consistency and evidence quality will be assessed. ETHICS AND DISSEMINATION There will be no need of ethics approval as this systematic review is summary and analysis of existing literature. Final results may be presented in international conferences or a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42022322685.
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Affiliation(s)
- Zheng Wang
- Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, People's Republic of China
| | - Saixin Li
- Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, People's Republic of China
| | - Kenan Wang
- Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, People's Republic of China
| | - Min Zhang
- Department of Anesthesiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jie Wu
- Department of Anesthesiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Dongbin Liu
- Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, People's Republic of China
| | - Kuo Liang
- Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, People's Republic of China
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Han E, Kim MK, Lee HW, Ryu S, Kim HS, Jang BK, Suh Y. Muscle fat contents rather than muscle mass determines nonalcoholic steatohepatitis and liver fibrosis in patients with severe obesity. Obesity (Silver Spring) 2022; 30:2440-2449. [PMID: 36319600 DOI: 10.1002/oby.23576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study aimed to investigate the association of muscle fat contents, nonalcoholic steatohepatitis (NASH), and liver fibrosis in patients with severe obesity. METHODS Patients with severe obesity who underwent bariatric surgery were evaluated for NASH and liver fibrosis. Skeletal muscle was assessed by dual energy x-ray absorptiometry, and muscle fat contents (skeletal muscle fat index [SMFI]) were evaluated by computed tomography-based psoas muscle mass and density. RESULTS A total of 104 patients with severe obesity were enrolled (57 with nonalcoholic fatty liver disease activity score <5 and 47 with NASH with nonalcoholic fatty liver disease activity score ≥5). SMFI was higher in patients with NASH than those without NASH (mean [SD], 39.0 [14.5] vs. 46.5 [14.2] for without NASH vs. with NASH; p = 0.009). SMFI was also correlated with hepatic steatosis grade, ballooning severity, and fibrosis stage. Multiple logistic regression analysis showed that SMFI was associated with higher risk of NASH and liver fibrosis (odds ratio = 2.37, 95% CI: 1.13-4.98, p = 0.022 for NASH; odds ratio = 2.93, 95% CI: 1.32-6.48, p = 0.008 for significant liver fibrosis). CONCLUSIONS Muscle fat infiltration rather than muscle mass reflects the severities of hepatic steatosis and fibrosis in patients with severe obesity.
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Affiliation(s)
- Eugene Han
- Division of Endocrinology & Metabolism, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, South Korea
| | - Mi Kyung Kim
- Division of Endocrinology & Metabolism, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, South Korea
| | - Hye Won Lee
- Department of Pathology, Keimyung University School of Medicine, Daegu, South Korea
| | - Seungwan Ryu
- Division of Gastrointestinal Surgery, Department of Surgery, Keimyung University School of Medicine, Daegu, South Korea
| | - Hye Soon Kim
- Division of Endocrinology & Metabolism, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, South Korea
| | - Byoung Kuk Jang
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, South Korea
| | - Youngsung Suh
- Department of Family Medicine, Keimyung University School of Medicine, Daegu, South Korea
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Santos CMDL, Brito MD, Castro PASVD, Vries TPD, Viana NL, Coelho MPP, Malheiro OB, Bering T, Gonzalez MC, Teixeira R, Cambraia RD, Rocha GA, Silva LD. Metabolic-associated fatty liver disease is associated with low muscle mass and strength in patients with chronic hepatitis B. World J Hepatol 2022; 14:1652-1666. [PMID: 36157867 PMCID: PMC9453457 DOI: 10.4254/wjh.v14.i8.1652] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/04/2022] [Accepted: 08/16/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although the prognostic relevance of sarcopenia has been increasingly recognised in the context of liver disease, there is a paucity of data evaluating body composition in patients with chronic hepatitis B (CHB). Beyond virus-related factors, nutritional and metabolic aspects can be associated with skeletal muscle abnormalities in these patients and should not be disregarded.
AIM To evaluate the association between components of sarcopenia and demographic, clinical, lifestyle, nutritional, and biochemical variables in CHB patients.
METHODS Dual-energy X-ray absorptiometry (DXA) was used to assess muscle mass by quantifying appendicular lean mass (ALM) adjusted for body mass index (ALMBMI). Muscle function was evaluated by hand grip strength (HGS) and the timed up and go test. Metabolic-associated fatty liver disease (MAFLD) was defined according to the criteria proposed by an international expert panel. A body shape index and the International Physical Activity Questionnaire were used to assess central obesity and physical activity level, respectively.
RESULTS This cross-sectional study included 105 CHB outpatients followed at the tertiary care ambulatory centre (mean age, 48.5 ± 12.0 years; 58.1% males; 76.2% without cirrhosis; 23.8% with compensated cirrhosis). The DXA-derived fat mass percentage was inversely correlated with the ALMBMI (r = - 0.87) and HGS (r = - 0.63). In the multivariable analysis, MAFLD, sedentarism and central obesity were positively and independently associated with low ALMBMI. MAFLD and central obesity were independently associated with low HGS.
CONCLUSION MAFLD and central obesity were associated with low muscle mass and strength in patients with chronic hepatitis B, independent of the liver disease stage.
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Affiliation(s)
- Cecy Maria de Lima Santos
- Sciences Applied to Adult Health Care Post-Graduate Programme Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
- Outpatient Clinic of Viral Hepatitis, Instituto Alfa de Gastroenterologia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Matheus Duarte Brito
- Outpatient Clinic of Viral Hepatitis, Instituto Alfa de Gastroenterologia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Pedro Alves Soares Vaz de Castro
- Outpatient Clinic of Viral Hepatitis, Instituto Alfa de Gastroenterologia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Thais Pontello de Vries
- Sciences Applied to Adult Health Care Post-Graduate Programme Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
- Outpatient Clinic of Viral Hepatitis, Instituto Alfa de Gastroenterologia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Nataly Lopes Viana
- Sciences Applied to Adult Health Care Post-Graduate Programme Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
- Outpatient Clinic of Viral Hepatitis, Instituto Alfa de Gastroenterologia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Marta Paula Pereira Coelho
- Sciences Applied to Adult Health Care Post-Graduate Programme Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Olívio Brito Malheiro
- Department of Locomotor System, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Tatiana Bering
- Department of Food and Nutrition, Universidade Federal de Mato Grosso, Cuiabá 78060-900, Mato Grosso, Brazil
| | - Maria Cristina Gonzalez
- Postgraduate Program in Health and Behaviour, Catholic University of Pelotas, Pelotas 96015-560, Rio Grande do Sul, Brazil
| | - Rosângela Teixeira
- Sciences Applied to Adult Health Care Post-Graduate Programme Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
- Outpatient Clinic of Viral Hepatitis, Instituto Alfa de Gastroenterologia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Rodrigo Dias Cambraia
- Outpatient Clinic of Viral Hepatitis, Instituto Alfa de Gastroenterologia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Gifone Aguiar Rocha
- Laboratory of Research in Bacteriology, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Luciana Diniz Silva
- Sciences Applied to Adult Health Care Post-Graduate Programme Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
- Outpatient Clinic of Viral Hepatitis, Instituto Alfa de Gastroenterologia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
- Department of Internal Medicine, Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, Minas Gerais, Brazil
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10
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Prevalence and Risk Factors of Cardiovascular Disease in Patients with Chronic Hepatitis B. Dig Dis Sci 2022; 67:3412-3425. [PMID: 34476661 DOI: 10.1007/s10620-021-07157-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 07/05/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND The association between chronic hepatitis B (CHB) and cardiovascular disease (CVD) remains unclear. We investigated the prevalence and risk factors of CVD in patients with CHB. METHODS Data from the Korean National Health and Nutrition Examination Surveys 2008-2011 were analyzed. Significant liver fibrosis was defined as the highest nonalcoholic fatty liver disease fibrosis score quartile, highest Forns index quintile, or fibrosis-4 ≥ 2.67. The CVD risk was calculated using the 10-year atherosclerotic cardiovascular disease (ASCVD) risk score from the 2013 ACC/AHA Guidelines. RESULTS Among the 506 subjects with CHB, 15 (3.0%) and 150 (29.6%) patients had a CVD history and significant liver fibrosis, respectively. Patients with CVD history were significantly older; showed a significantly higher prevalence of hypertension, metabolic syndrome, and significant liver fibrosis; and had a significantly higher platelet count, lower aspartate and alanine aminotransferase levels, higher triglyceride level, lower high-density lipoprotein level, and higher ASCVD risk than those without (all p < 0.05). In multivariate analysis, higher ASCVD risk (odds ratio [OR] = 1.090) and significant liver fibrosis (OR = 4.341) independently predicted the risk of CVD history (p < 0.05). The prevalence of CVD risk (6.7% vs. 1.4%; OR = 5.014) and high ASCVD risk (> 15%) (34.0% vs. 7.3%; OR = 6.538) was significantly higher in patients with significant liver fibrosis than in those without (all p < 0.05). CONCLUSIONS Significant liver fibrosis was independently associated with the risk of CVD history in patients with CHB. Prospective studies are needed to validate the longitudinal association between fibrotic burden and CVD development in patients with CHB.
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Cespiati A, Meroni M, Lombardi R, Oberti G, Dongiovanni P, Fracanzani AL. Impact of Sarcopenia and Myosteatosis in Non-Cirrhotic Stages of Liver Diseases: Similarities and Differences across Aetiologies and Possible Therapeutic Strategies. Biomedicines 2022; 10:biomedicines10010182. [PMID: 35052859 PMCID: PMC8773740 DOI: 10.3390/biomedicines10010182] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 12/15/2022] Open
Abstract
Sarcopenia is defined as a loss of muscle strength, mass and function and it is a predictor of mortality. Sarcopenia is not only a geriatric disease, but it is related to several chronic conditions, including liver diseases in both its early and advanced stages. Despite the increasing number of studies exploring the role of sarcopenia in the early stages of chronic liver disease (CLD), its prevalence and the relationship between these two clinical entities are still controversial. Myosteatosis is characterized by fat accumulation in the muscles and it is related to advanced liver disease, although its role in the early stages is still under researched. Therefore, in this narrative review, we firstly aimed to evaluate the prevalence and the pathogenetic mechanisms underlying sarcopenia and myosteatosis in the early stage of CLD across different aetiologies (mainly non-alcoholic fatty liver disease, alcohol-related liver disease and viral hepatitis). Secondly, due to the increasing prevalence of sarcopenia worldwide, we aimed to revise the current and the future therapeutic approaches for the management of sarcopenia in CLD.
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Affiliation(s)
- Annalisa Cespiati
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pad. Granelli, Via F Sforza 35, 20122 Milan, Italy; (A.C.); (M.M.); (G.O.); (P.D.); (A.L.F.)
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
| | - Marica Meroni
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pad. Granelli, Via F Sforza 35, 20122 Milan, Italy; (A.C.); (M.M.); (G.O.); (P.D.); (A.L.F.)
| | - Rosa Lombardi
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pad. Granelli, Via F Sforza 35, 20122 Milan, Italy; (A.C.); (M.M.); (G.O.); (P.D.); (A.L.F.)
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
- Correspondence: ; Tel.: +39-02-5503-4192; Fax: +39-02-5503-3509
| | - Giovanna Oberti
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pad. Granelli, Via F Sforza 35, 20122 Milan, Italy; (A.C.); (M.M.); (G.O.); (P.D.); (A.L.F.)
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
| | - Paola Dongiovanni
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pad. Granelli, Via F Sforza 35, 20122 Milan, Italy; (A.C.); (M.M.); (G.O.); (P.D.); (A.L.F.)
| | - Anna Ludovica Fracanzani
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Pad. Granelli, Via F Sforza 35, 20122 Milan, Italy; (A.C.); (M.M.); (G.O.); (P.D.); (A.L.F.)
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
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Yang Y, Ju L, Fan J, Cai S, Sun L, Li Y. Association of urinary phthalate metabolites with sarcopenia in US adults: NHANES 1999-2006. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:7573-7582. [PMID: 34480309 DOI: 10.1007/s11356-021-16202-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/24/2021] [Indexed: 06/13/2023]
Abstract
Phthalates have been extensively detected in environmental and biological matrices. Exposure to phthalates is implicated in various human diseases. In this study, we conducted a cross-sectional study to determine whether urinary phthalate metabolite concentrations were correlated with prevalence of sarcopenia in US adult population. We included 3562 participants with detailed information on skeletal muscle mass and urinary phthalate metabolites based on National Health and Nutrition Examination Survey (NHANES) 1999-2006 data. A total of 7 main phthalate metabolites were analyzed in the urine sample of each participant. Appendicular skeletal muscle mass (ASM) was measured using dual-energy X-ray absorptiometry. Multivariable linear regression models were conducted following adjustment for multiple covariates. ASM adjusted by body mass index (ASM/BMI) was calculated, and sarcopenia was defined as the lowest quintile for ASM/BMI value. Compared with participants in quartile 1, those in quartile 2 of urinary mono-n-butyl phthalate (MnBP) and quartile 4 of urinary monobenzyl phthalate (MBzP) had decreased ASM/BMI. Urinary MnBP in quartile 4, as well as urinary MBzP in quartile 2, was shown to be significantly correlated with higher sarcopenia prevalence. In subgroup analysis, negative association of MBzP with ASM/BMI was observed in both males and females, while this negative association was only observed in males for MnBP. Females with higher urinary monoethyl phthalate (MEP) concentrations had higher sarcopenia risk. Taken together, the present study found several urinary phthalate metabolites were positively associated with sarcopenia prevalence in US adult population. These findings indicated phthalate exposure might be an important environmental risk factor contributing to sarcopenia development.
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Affiliation(s)
- Ye Yang
- Department of Epidemiology and Health Statistics, School of Public Health, Hangzhou Medical College, 481 Binwen Road, Hangzhou, 310053, China
| | - Li Ju
- Department of Epidemiology and Health Statistics, School of Public Health, Hangzhou Medical College, 481 Binwen Road, Hangzhou, 310053, China
| | - Jiayao Fan
- Department of Epidemiology and Health Statistics, School of Public Health, Hangzhou Medical College, 481 Binwen Road, Hangzhou, 310053, China
| | - Shaofang Cai
- Department of Science and Education, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Lingling Sun
- Department of Orthopaedics, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yingjun Li
- Department of Epidemiology and Health Statistics, School of Public Health, Hangzhou Medical College, 481 Binwen Road, Hangzhou, 310053, China.
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Chun HS, Kim MN, Lee JS, Lee HW, Kim BK, Park JY, Kim DY, Ahn SH, Kim SU. Risk stratification using sarcopenia status among subjects with metabolic dysfunction-associated fatty liver disease. J Cachexia Sarcopenia Muscle 2021; 12:1168-1178. [PMID: 34337887 PMCID: PMC8517359 DOI: 10.1002/jcsm.12754] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/08/2021] [Accepted: 06/15/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Sarcopenia is a significant indicator of the severity of non-alcoholic fatty liver disease. We investigated whether sarcopenia could identify subgroups with different risk of liver fibrosis and atherosclerotic cardiovascular disease (ASCVD) among subjects with metabolic dysfunction-associated fatty liver disease (MAFLD). METHODS Subjects from the Korea National Health and Nutrition Examination Survey 2008-2011 were selected (n = 8361). Sarcopenia was defined using the sarcopenia index. Hepatic steatosis was defined as a fatty liver index ≥30. Significant liver fibrosis was defined as a fibrosis-4 index (FIB-4) ≥2.67 or the highest quartile of non-alcoholic fatty liver disease fibrosis score (NFS). High probability of ASCVD was defined as ASCVD risk score >10%. RESULTS The mean age was 48.5 ± 15.6 years, and 42.6% of subjects were male. The prevalence of MAFLD was 37.3% (n = 3116 of 8361), and the proportion of sarcopenic subjects was 9.9% among those with MAFLD. After adjusting for confounders, the risk of significant liver fibrosis significantly increased from non-sarcopenic subjects with MAFLD [odds ratio (OR) = 1.57 by FIB-4 and 2.13 by NFS] to sarcopenic subjects with MAFLD (OR = 4.51 by FIB-4 and 5.72 by NFS), compared with subjects without MAFLD (all P < 0.001). The risk for high probability of ASCVD significantly increased from non-sarcopenic subjects with MAFLD (OR = 1.47) to sarcopenic subjects with MAFLD (OR = 4.08), compared with subjects without MAFLD (all P < 0.001). CONCLUSIONS The risks of significant liver fibrosis and ASCVD differed significantly according to sarcopenic status among subjects with MAFLD. An assessment of sarcopenia might be helpful in risk stratification among subjects with MAFLD.
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Affiliation(s)
- Ho Soo Chun
- Department of Internal MedicineEwha Womans University Medical CenterSeoulKorea
- Department of Internal MedicineEwha Womans University College of MedicineSeoulKorea
| | - Mi Na Kim
- Division of Gastroenterology, Department of Internal Medicine, CHA Bundang Medical CenterCHA University School of MedicineSeongnamKorea
- Clinical and Translational Hepatology LaboratorySeongnamKorea
| | - Jae Seung Lee
- Department of Internal MedicineYonsei University College of MedicineSeoulKorea
- Yonsei Liver CenterSeverance HospitalSeoulKorea
| | - Hye Won Lee
- Department of Internal MedicineYonsei University College of MedicineSeoulKorea
- Yonsei Liver CenterSeverance HospitalSeoulKorea
| | - Beom Kyung Kim
- Department of Internal MedicineYonsei University College of MedicineSeoulKorea
- Yonsei Liver CenterSeverance HospitalSeoulKorea
| | - Jun Yong Park
- Department of Internal MedicineYonsei University College of MedicineSeoulKorea
- Yonsei Liver CenterSeverance HospitalSeoulKorea
| | - Do Young Kim
- Department of Internal MedicineYonsei University College of MedicineSeoulKorea
- Yonsei Liver CenterSeverance HospitalSeoulKorea
| | - Sang Hoon Ahn
- Department of Internal MedicineYonsei University College of MedicineSeoulKorea
- Yonsei Liver CenterSeverance HospitalSeoulKorea
| | - Seung Up Kim
- Department of Internal MedicineYonsei University College of MedicineSeoulKorea
- Yonsei Liver CenterSeverance HospitalSeoulKorea
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Sung MJ, Lim TS, Jeon MY, Lee HW, Kim BK, Kim DY, Ahn SH, Han KH, Park JY, Kim SU. Sarcopenia Is Independently Associated with the Degree of Liver Fibrosis in Patients with Type 2 Diabetes Mellitus. Gut Liver 2021; 14:626-635. [PMID: 32135582 PMCID: PMC7492504 DOI: 10.5009/gnl19126] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/26/2019] [Accepted: 09/19/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Sarcopenia is associated with liver fibrosis in patients with nonalcoholic fatty liver disease and chronic hepatitis B. We investigated the association between sarcopenia and hepatic fibrotic burden in patients with type 2 diabetes mellitus (T2DM). Methods Patients with T2DM who had received a comprehensive medical health check-up were recruited. Muscle mass was assessed using computed tomography. Fibrotic burden was assessed using the fibrosis-4 index (FIB-4). The study population was divided by quartile stratification of the lumbar skeletal muscle index (LSMI). Results Among 309 patients with T2DM, 75 (24.3%) had sarcopenia. These patients were significantly older and had higher FIB-4, whereas they had significantly lower body mass index (BMI) and LSMI than patients without sarcopenia (all p<0.05). The LSMI showed a significant negative correlation with the FIB-4 when analyzed in terms of quartile stratification (p=0.003). Multivariate analysis showed that female sex and higher BMI were independently associated with a reduced risk of sarcopenia (odds ratio [OR], 0.388; 95% confidence interval [CI], 0.199 to 0.755 and OR, 0.704; 95% CI, 0.618 to 0.801; all p<0.05), whereas a higher FIB-4 was independently associated with an increased risk of sarcopenia (OR, 1.817; 95% CI, 1.180 to 2.797; p=0.007). Among patients with a BMI <25 kg/m2 (n=165), those with sarcopenia (n=54, 32.7%) had a significantly higher FIB-4 than those without (n=111, 67.3%; 1.66 vs 1.38, p=0.004). Conclusions Sarcopenia is independently associated with fibrotic burden in patients with T2DM. Further studies should investigate whether the improvement of sarcopenia can ameliorate liver fibrosis in patients with T2DM.
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Affiliation(s)
- Min Je Sung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Seop Lim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea
| | - Mi Young Jeon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea
| | - Hye Won Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Do Young Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang-Hyub Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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15
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Chun HS, Park S, Lee M, Cho Y, Kim HS, Choe AR, Kim HY, Yoo K, Kim TH. Association of Physical Activity with the Risk of Hepatocellular Carcinoma in Patients with Chronic Hepatitis B. Cancers (Basel) 2021; 13:cancers13143424. [PMID: 34298640 PMCID: PMC8306325 DOI: 10.3390/cancers13143424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 06/17/2021] [Accepted: 06/28/2021] [Indexed: 12/22/2022] Open
Abstract
Simple Summary Although viral replication in patients with a chronic hepatitis B (CHB) infection is effectively suppressed by potent antiviral therapy such as entecavir or tenofovir, the risk of hepatocellular carcinoma (HCC) development in CHB patients cannot be totally eliminated. Thus, control of modifiable risk factors for HCC development such as lifestyle modification is important to minimize the HCC risk. In this study, we analyzed a nationwide population-based cohort to evaluate whether there is a significant association between physical activity and development of HCC in CHB patients treated with entecavir or tenofovir. Results in this study suggest that physical activity was significantly associated with a lower risk of HCC development in CHB patients treated with potent antiviral therapy. Increasing physical activity can have beneficial outcomes on HCC development in CHB patients treated with entecavir or tenofovir. Abstract Background and Aims: In the general population, previous studies reported that physical activity was associated with risk of hepatocellular carcinoma (HCC) development. However, it is unclear whether physical activity is associated with risk of HCC development in patients with chronic hepatitis B (CHB). We aimed to elucidate the association between physical activity and risk of HCC development in CHB patients. Methods: This nationwide cohort study involved treatment-naive patients with CHB (n = 9727) who started treatment with entecavir or tenofovir and answered self-reported questionnaires between January 2012 and December 2017, using data from the Korean National Health Insurance Service database. The primary endpoint was development of HCC. Multivariable Cox regression and competing risk analyses were used. Results: During a median follow-up of 3.1 years, cumulative HCC incidence rates were 8.3%. There was an inverse association between physical activity and the risk of HCC (p < 0.001). Patients with 1000–1500 metabolic equivalent task (MET)-min/week, compared to those without physical activity, showed a significantly lower risk of HCC in both patients without cirrhosis (adjusted hazard ratio [aHR] 0.66, p = 0.02) and patients with cirrhosis (aHR 0.61, p = 0.02). In patients who were younger (<60), male, without diabetes, and with high BMI, amounts of physical activity of 1000–1500 MET-min/week showed an inverse association with the risk of HCC (aHR 0.65, 0.63, 0.65, and 0.64, respectively, all p < 0.05). Conclusion: Physical activity was significantly associated with a low risk of HCC in CHB patients treated with entecavir or tenofovir.
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Affiliation(s)
- Ho Soo Chun
- Ewha Womans University Medical Center, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul 07804, Korea; (H.S.C.); (A.R.C.); (H.Y.K.); (K.Y.)
| | - Sojeong Park
- Data Science Team, Hanmi Pharmaceutical Co., Ltd., Seoul 05545, Korea; (S.P.); (H.S.K.)
| | - Minjong Lee
- Ewha Womans University Medical Center, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul 07804, Korea; (H.S.C.); (A.R.C.); (H.Y.K.); (K.Y.)
- Correspondence: (M.L.); (T.H.K.); Tel.: +82-2-6986-1761 (M.L.); +82-2-6986-1621 (T.H.K.)
| | - Yuri Cho
- National Cancer Center, Center for Liver and Pancreatobiliary Cancer, Goyang 10408, Korea;
| | - Ha Sung Kim
- Data Science Team, Hanmi Pharmaceutical Co., Ltd., Seoul 05545, Korea; (S.P.); (H.S.K.)
| | - A Reum Choe
- Ewha Womans University Medical Center, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul 07804, Korea; (H.S.C.); (A.R.C.); (H.Y.K.); (K.Y.)
| | - Hwi Young Kim
- Ewha Womans University Medical Center, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul 07804, Korea; (H.S.C.); (A.R.C.); (H.Y.K.); (K.Y.)
| | - Kwon Yoo
- Ewha Womans University Medical Center, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul 07804, Korea; (H.S.C.); (A.R.C.); (H.Y.K.); (K.Y.)
| | - Tae Hun Kim
- Ewha Womans University Medical Center, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul 07804, Korea; (H.S.C.); (A.R.C.); (H.Y.K.); (K.Y.)
- Correspondence: (M.L.); (T.H.K.); Tel.: +82-2-6986-1761 (M.L.); +82-2-6986-1621 (T.H.K.)
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Baek W, Lee JW, Lee HS, Han D, Choi SY, Chun EJ, Han HW, Park SH, Sung J, Jung HO, Lee H, Chang HJ. Concurrent smoking and alcohol consumers had higher triglyceride glucose indices than either only smokers or alcohol consumers: a cross-sectional study in Korea. Lipids Health Dis 2021; 20:49. [PMID: 33975592 PMCID: PMC8111749 DOI: 10.1186/s12944-021-01472-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 04/20/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The triglyceride glucose (TyG) index is a noninsulin-based marker for insulin resistance (IR) in general practice. Although smoking and heavy drinking have been regarded as major risk factors for various chronic diseases, there is limited evidence regarding the combined effects of smoking and alcohol consumption on IR. This study aimed to investigate the relationship between the TyG index and smoking and alcohol consumption using two Korean population-based datasets. METHODS This study included 10,568 adults in the Korean National Health and Nutrition Examination Survey (KNHANES) and 9586 adults in the Korean Initiatives on Coronary Artery Calcification (KOICA) registry datasets. Multivariate logistic analysis was conducted to explore the relationship between smoking and alcohol consumption and the TyG index. To assess the predictive value of smoking and alcohol consumption on high TyG index, the area under the curve (AUC) were compared and net reclassification improvement (NRI) and integrated discrimination improvement (IDI) analyses were derived. RESULTS The combined effect of smoking and alcohol consumption was an independent risk factor of a higher TyG index in the KNHANES (adjusted odds ratio: 4.33, P < .001) and KOICA (adjusted odds ratio: 1.94, P < .001) datasets. Adding smoking and alcohol consumption to the multivariate logistic models improved the model performance for the TyG index in the KNHANES (AUC: from 0.817 to 0.829, P < .001; NRI: 0.040, P < .001; IDI: 0.017, P < .001) and KOICA (AUC: from 0.822 to 0.826, P < .001; NRI: 0.025, P = .006; IDI: 0.005, P < .001) datasets. CONCLUSIONS Smoking and alcohol consumption were independently associated with the TyG index. Concurrent smokers and alcohol consumers were more likely to have a TyG index that was ≥8.8 and higher than the TyG indices of non-users and those who exclusively consumed alcohol or smoking tobacco.
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Affiliation(s)
- Wonhee Baek
- Department of Nursing, Yonsei University Graduate School, Seoul, Republic of Korea.,Department of Nursing, Kyungnam University College of Health Sciences, Changwon, Republic of Korea
| | - Ji-Won Lee
- Department of Family Medicine, Yonsei University College of Medicine Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Department of Research Affairs, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Donghee Han
- Department of Imaging and Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Su-Yeon Choi
- Division of Cardiology, Seoul National University Healthcare System Gangnam Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun Ju Chun
- Department of Radiology, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Hae-Won Han
- Department of Internal Medicine, Gangnam Heartscan Clinic, Seoul, Republic of Korea
| | - Sung Hak Park
- Department of Radiology, Gangnam Heartscan Clinic, Seoul, Republic of Korea
| | - Jidong Sung
- Division of Cardiology, Department of Medicine, Sungkyunkwan University School of Medicine, Heart Stroke and Vascular Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Hae Ok Jung
- Division of Cardiology, Cardiovascular Center, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyangkyu Lee
- Department of Nursing, Yonsei University Graduate School, Seoul, Republic of Korea. .,Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea.
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Son SW, Song DS, Chang UI, Yang JM. Definition of Sarcopenia in Chronic Liver Disease. Life (Basel) 2021; 11:349. [PMID: 33923561 PMCID: PMC8074027 DOI: 10.3390/life11040349] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 02/07/2023] Open
Abstract
Sarcopenia, which is characterized by decline in muscle mass, muscle strength, and physical performance, is common in patients with chronic liver disease (CLD) and is associated with poor clinical outcomes. Several consensus definitions for community-dwelling elderly people have been proposed, and these recommend the use of various tools and tests to assess muscle properties and performance. These measurement tools have also been applied in patients with CLD and have been useful for predicting prognosis. However, sarcopenia and its diagnostic criteria specific to patients with CLD have not yet been clearly defined. In addition, fluid retention and body composition should be considered when sarcopenia is assessed in patients with CLD. This review aims to introduce definitions of sarcopenia and diagnostic tools used in patients with CLD.
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Affiliation(s)
| | - Do Seon Song
- Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.W.S.); (U.I.C.); (J.M.Y.)
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Sarcopenic Obesity in Liver Cirrhosis: Possible Mechanism and Clinical Impact. Int J Mol Sci 2021; 22:ijms22041917. [PMID: 33671926 PMCID: PMC7919019 DOI: 10.3390/ijms22041917] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 02/07/2023] Open
Abstract
The picture of chronic liver diseases (CLDs) has changed considerably in recent years. One of them is the increase of non-alcoholic fatty liver disease. More and more CLD patients, even those with liver cirrhosis (LC), tend to be presenting with obesity these days. The annual rate of muscle loss increases with worsening liver reserve, and thus LC patients are more likely to complicate with sarcopenia. LC is also characterized by protein-energy malnutrition (PEM). Since the PEM in LC can be invariable, the patients probably present with sarcopenic obesity (Sa-O), which involves both sarcopenia and obesity. Currently, there is no mention of Sa-O in the guidelines; however, the rapidly increasing prevalence and poorer clinical consequences of Sa-O are recognized as an important public health problem, and the diagnostic value of Sa-O is expected to increase in the future. Sa-O involves a complex interplay of physiological mechanisms, including increased inflammatory cytokines, oxidative stress, insulin resistance, hormonal disorders, and decline of physical activity. The pathogenesis of Sa-O in LC is diverse, with a lot of perturbations in the muscle-liver-adipose tissue axis. Here, we overview the current knowledge of Sa-O, especially focusing on LC.
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Lee CM, Kang BK, Kim M. Radiologic Definition of Sarcopenia in Chronic Liver Disease. Life (Basel) 2021; 11:86. [PMID: 33504046 PMCID: PMC7910987 DOI: 10.3390/life11020086] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/18/2021] [Accepted: 01/21/2021] [Indexed: 12/14/2022] Open
Abstract
Sarcopenia is prevalent in patients with chronic liver disease, and affected patients tend to have worse clinical outcomes and higher mortality. However, relevant analyses are limited by heterogeneity in the definition of sarcopenia and in the methodological approaches in assessing it. We reviewed several radiologic methods for sarcopenia in patients with chronic liver disease. Dual energy X-ray absorptiometry (DXA) can measure muscle mass, but it is difficult to evaluate muscle quality using this technique. Computed tomography, known as the gold standard for diagnosing sarcopenia, enables the objective measurement of muscle quantity and quality. The third lumbar skeletal muscle index (L3 SMI) more accurately predicted the mortality of subjects than the psoas muscle index (PMI). Few studies have evaluated the sarcopenia of chronic liver disease using ultrasonography and magnetic resonance imaging, and more studies are needed. Unification of the measurement method and cut-off value would facilitate a more systematic and universal prognosis evaluation in patients with chronic liver disease.
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Affiliation(s)
| | | | - Mimi Kim
- Department of Radiology, College of Medicine, Hanyang University, Seoul 04763, Korea; (C.-m.L.); (B.K.K.)
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20
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Radiologic Definition of Sarcopenia in Chronic Liver Disease. LIFE (BASEL, SWITZERLAND) 2021. [PMID: 33504046 DOI: 10.3390/life11020086.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Sarcopenia is prevalent in patients with chronic liver disease, and affected patients tend to have worse clinical outcomes and higher mortality. However, relevant analyses are limited by heterogeneity in the definition of sarcopenia and in the methodological approaches in assessing it. We reviewed several radiologic methods for sarcopenia in patients with chronic liver disease. Dual energy X-ray absorptiometry (DXA) can measure muscle mass, but it is difficult to evaluate muscle quality using this technique. Computed tomography, known as the gold standard for diagnosing sarcopenia, enables the objective measurement of muscle quantity and quality. The third lumbar skeletal muscle index (L3 SMI) more accurately predicted the mortality of subjects than the psoas muscle index (PMI). Few studies have evaluated the sarcopenia of chronic liver disease using ultrasonography and magnetic resonance imaging, and more studies are needed. Unification of the measurement method and cut-off value would facilitate a more systematic and universal prognosis evaluation in patients with chronic liver disease.
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21
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Chang JW, Lee HW, Kim BK, Park JY, Kim DY, Ahn SH, Han KH, Kim SU. Hepatic Steatosis Index in the Detection of Fatty Liver in Patients with Chronic Hepatitis B Receiving Antiviral Therapy. Gut Liver 2021; 15:117-127. [PMID: 32066210 PMCID: PMC7817922 DOI: 10.5009/gnl19301] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 12/13/2019] [Accepted: 12/21/2019] [Indexed: 12/12/2022] Open
Abstract
Background/Aims The hepatic steatosis index (HSI) is a noninvasive method to assess the severity of hepatic steatosis. Antiviral therapy (AVT) can impact aspartate aminotransferase and alanine aminotransferase levels, which are the main components of the HSI. Thus, we investigated the accuracy of the HSI in detecting hepatic steatosis in patients with chronic hepatitis B (CHB) receiving AVT, compared with those not receiving AVT and in those with nonalcoholic fatty liver disease (NAFLD). Methods Patients with CHB or NAFLD who underwent a magnetic resonance imaging proton density fat fraction (MRI-PDFF) evaluation between March 2010 and March 2019 were recruited. Hepatic steatosis was diagnosed when the PDFF exceeded 5%. Area under the receiver operating characteristic curve (AUROC) analysis was used to assess the diagnostic accuracy of the HSI in the detection of hepatic steatosis. Results The mean age of the study population (189 men and 116 women; 244 with CHB [184 with and 60 without AVT] and 61 with NAFLD) was 55.6 years. The AUROC values for detecting hepatic steatosis were similar between patients with CHB (0.727; p<0.001) and those with NAFLD (0.739; p=0.002). However, when patients with CHB were subdivided into those receiving and not receiving AVT, the AUROC value decreased slightly in patients with CHB receiving AVT compared to those without not receiving AVT (0.707; p=0.001 vs 0.779; p=0.001). Conclusions Despite a slight attenuation, the diagnostic accuracy of the HSI in patients with CHB receiving AVT in detecting hepatic steatosis was still acceptable. Further large-scale studies are required for validation.
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Affiliation(s)
- Jin Won Chang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Won Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Do Young Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang-Hyub Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Yonsei Liver Center, Severance Hospital, Seoul, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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22
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Association between liver fibrosis and appendicular skeletal muscle mass during antiviral therapy in chronic hepatitis B. Dig Liver Dis 2020; 52:1338-1345. [PMID: 32771386 DOI: 10.1016/j.dld.2020.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/08/2020] [Accepted: 07/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Sarcopenia is associated with fibrotic burden in patients with chronic hepatitis B. We investigated the dynamic association between fibrosis changes and appendicular skeletal muscle mass during antiviral therapy in patients with chronic hepatitis B. METHODS Between 2015 and 2018, chronic hepatitis B patients who received paired transient elastography to assess fibrotic burden in the liver and bioelectrical impedance analysis to assess appendicular skeletal muscle mass were recruited retrospectively. The sarcopenia index was calculated as total appendicular skeletal muscle mass/body mass index. Significant liver fibrosis was defined as a liver stiffness value≥8 kPa. RESULTS In total, 223 (53.7%) received antiviral therapy, whereas 192 (46.3%) did not. Appendicular skeletal muscle mass decreased significantly in the antiviral therapy group (mean 21.16→21.00 kg, P = 0.01), but not in the non-antiviral therapy group (mean 20.77→20.64 kg, P = 0.134). In a subgroup with significant liver fibrosis, similar findings were observed (mean 20.73→20.54 kg in antiviral therapy group, P = 0.037; mean 21.39→21.07 kg in the non-antiviral therapy group, P = 0.097). Older age, male gender, higher body mass index, and higher aspartate aminotransferase were significantly associated with the increased risk of appendicular skeletal muscle mass reduction (≥5% from the baseline). CONCLUSIONS Appendicular skeletal muscle mass significantly decreased during antiviral therapy in patients with chronic hepatitis B patients.
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23
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Melchor SJ, Hatter JA, Castillo ÉAL, Saunders CM, Byrnes KA, Sanders I, Abebayehu D, Barker TH, Ewald SE. T. gondii infection induces IL-1R dependent chronic cachexia and perivascular fibrosis in the liver and skeletal muscle. Sci Rep 2020; 10:15724. [PMID: 32973293 PMCID: PMC7515928 DOI: 10.1038/s41598-020-72767-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/03/2020] [Indexed: 02/06/2023] Open
Abstract
Cachexia is a progressive muscle wasting disease that contributes to death in a wide range of chronic diseases. Currently, the cachexia field lacks animal models that recapitulate the long-term kinetics of clinical disease, which would provide insight into the pathophysiology of chronic cachexia and a tool to test therapeutics for disease reversal. Toxoplasma gondii (T. gondii) is a protozoan parasite that uses conserved mechanisms to infect rodents and human hosts. Infection is lifelong and has been associated with chronic weight loss and muscle atrophy in mice. We have recently shown that T. gondii-induced muscle atrophy meets the clinical definition of cachexia. Here, the longevity of the T. gondii-induced chronic cachexia model revealed that cachectic mice develop perivascular fibrosis in major metabolic organs, including the adipose tissue, skeletal muscle, and liver by 9 weeks post-infection. Development of cachexia, as well as liver and skeletal muscle fibrosis, is dependent on intact signaling through the type I IL-1R receptor. IL-1α is sufficient to activate cultured fibroblasts and primary hepatic stellate cells (myofibroblast precursors in the liver) in vitro, and IL-1α is elevated in the sera and liver of cachectic, suggesting a mechanism by which chronic IL-1R signaling could be leading to cachexia-associated fibrosis.
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Affiliation(s)
- Stephanie J Melchor
- Department of Microbiology, Immunology, and Cancer Biology and The Carter Immunology Center, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Jessica A Hatter
- Department of Pharmacology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Claire M Saunders
- Department of Microbiology, Immunology, and Cancer Biology and The Carter Immunology Center, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Kari A Byrnes
- Department of Microbiology, Immunology, and Cancer Biology and The Carter Immunology Center, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Imani Sanders
- Department of Microbiology, Immunology, and Cancer Biology and The Carter Immunology Center, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Daniel Abebayehu
- Department of Biomedical Engineering, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Thomas H Barker
- Department of Biomedical Engineering, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Sarah E Ewald
- Department of Microbiology, Immunology, and Cancer Biology and The Carter Immunology Center, University of Virginia School of Medicine, Charlottesville, VA, USA.
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24
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Han E, Cho Y, Kim KW, Lee YH, Kang ES, Cha BS, Lee BW. Hepatic fibrosis is associated with total proteinuria in Korean patients with type 2 diabetes. Medicine (Baltimore) 2020; 99:e21038. [PMID: 32871978 PMCID: PMC7437801 DOI: 10.1097/md.0000000000021038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The association between non-alcoholic fatty liver disease (NAFLD) and diabetic kidney disease assessed using either albuminuria or proteinuria remains controversial. This study aimed to investigate the association between hepatic steatosis or fibrosis and albuminuria or proteinuria in Korean patients with type 2 diabetes mellitus (T2D).We enrolled 1108 patients with T2D and categorized as 3 groups; non-proteinuria (NP), isolated non-albumin proteinuria (iNAP), and albuminuria. Urinary albumin and protein levels were assessed as urinary albumin-to-creatinine ratio (uACR) and urinary protein-to-creatinine ratio (uPCR), respectively. Hepatic steatosis and fibrotic burden were assessed using the NAFLD liver fat score, Fibrosis-4 calculator (FIB-4) index, and NAFLD fibrosis score (NFS).The prevalence of significant steatosis was similar among groups (NP: 74.6% vs iNAP: 70.3% vs albuminuria: 79.9%, P = .085). The prevalence of significant fibrosis was significantly higher in the iNAP (18.7%) and albuminuria (16.5%) groups than in the NP group (9.5%, P = .001). Both uPCR and uACR showed a correlation with NFS (uPCR: r = 0.123, P < .001; uACR: r = 0.064, P = .033). In multivariate logistic regression analysis, uPCR ≥150 mg/g was found to have a stronger association with hepatic fibrosis than uACR ≥30 mg/g (adjusted odds ratio 1.55 [95% CI 1.03-2.33] vs adjusted odds ratio 1.16 [95% CI, 0.72-1.87]).In conclusion, patients with iNAP and albuminuria had a higher prevalence of hepatic fibrosis than those without proteinuria. Total proteinuria was associated with advanced liver fibrosis, whereas albuminuria was related to hepatic steatosis.
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Affiliation(s)
- Eugene Han
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu
| | - Yongin Cho
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung-won Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-ho Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Seok Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Bong-Soo Cha
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung-wan Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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25
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Li JB, Wu Y, Gu D, Li H, Zhang X. Prevalence and temporal trends of presarcopenia metrics and related body composition measurements from the 1999 to 2006 NHANES. BMJ Open 2020; 10:e034495. [PMID: 32759238 PMCID: PMC7410000 DOI: 10.1136/bmjopen-2019-034495] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To evaluate the prevalence and temporal trends of presarcopenia and related body composition measurements. DESIGN Cross-sectional study. SETTING National Health and Nutrition Examination Survey (NHANES) 1999-2006. METHODS Presarcopenia was defined according to the guidelines from the European Working Group on Sarcopenia. Logistic or linear regression models were used to evaluate the linear trend of the prevalence of presarcopenia, obesity and related body composition measurements. PARTICIPANTS A total of 29 947 participants aged 18-90 years from five waves of the NHANES were included in the analysis. OUTCOME MEASURES Presarcopenia was sex-specifically defined as having a skeletal mass index ≤7.26 kg/m2 in men and ≤5.5 kg/m2 in women. Body composition measurements, including total body fat percentage, total body fat mass, total lean body mass, appendicular skeletal muscle mass and bone mineral density, were obtained by dual-energy X-ray absorptiometry. RESULTS The overall prevalence of presarcopenia ranged from 16.4% in 1999-2000 to 14.8% in 2005-2006 (p for trend=0.78). Presarcopenia was stable in both males (p for trend=0.36) and females (p for trend=0.20). The presarcopenia prevalence was significantly elevated among the age group of 18-39 years old (from 11.3% to 14.1%, p for trend=0.04) and among non-Hispanic blacks (p for trend <0.001). Adults aged ≥80 years old had the highest prevalence. CONCLUSIONS The prevalence of presarcopenia increased among young individuals over time. Non-Hispanic blacks also demonstrated an increasing trend in the prevalence over time.
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Affiliation(s)
- Ji-Bin Li
- Department of Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yuwan Wu
- Department of Pediatrics, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Dantong Gu
- Department of Bio-statistics, Fudan University School of Public Health, Shanghai, China
| | - Huajun Li
- Department of Pediatrics, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xi Zhang
- Clinical Research Unit, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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26
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Barbero-Becerra VJ, López-Méndez I, Romo-Araiza A, Visag-Castillo V, Chávez-Tapia NC, Uribe M, Juárez-Hernandez E. Sarcopenia in chronic liver diseases: a translational overview. Expert Rev Gastroenterol Hepatol 2020; 14:355-366. [PMID: 32299261 DOI: 10.1080/17474124.2020.1757427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Sarcopenia refers to a progressive and generalized muscle mass and strength loss. In liver diseases, it has been related to worse outcomes and high risk of decompensations. AREAS COVERED Sarcopenia is caused by a set of cellular processes in the muscle such as denervation, mitochondrial dysfunction, endotoxemia and inflammation; which are manifested through the alteration of several proteolytic pathways such as lysosomal, proteasomal and caspase systems. In autophagy, myostatin and oxidative stress; such as hyperammonemia, contributes importantly to liver sarcopenia through loss of muscle mass already demonstrated in in vitro and in vivo models. In addition, hormones and the regulation of the intestinal microbiota, influence in a not less important magnitude. In the clinical setting, early identification of sarcopenia has been established as a mandatory item to prevent progression of muscle mass loss; however, diagnostic methods have extreme variation according to methodology, population, etiology and severity of liver disease. Reversing sarcopenia should be an integral therapeutic strategy. EXPERT OPINION Clinical and nutritional interventions should be adapted to liver injury etiology and stage of disease, each of them shares a similar sarcopenia development pathway. There are specific biomarkers that condition or exacerbate loss of skeletal muscle.
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Affiliation(s)
| | - Iván López-Méndez
- Transplants and Hepatology Unit, Medica Sur Clinic & Foundation , Mexico City, Mexico
| | | | - Víctor Visag-Castillo
- Gastroenterology and Obesity Unit, Medica Sur Clinic & Foundation , Mexico City, Mexico
| | - Norberto C Chávez-Tapia
- Translational Research Unit, Medica Sur Clinic & Foundation , Mexico City, Mexico.,Gastroenterology and Obesity Unit, Medica Sur Clinic & Foundation , Mexico City, Mexico
| | - Misael Uribe
- Gastroenterology and Obesity Unit, Medica Sur Clinic & Foundation , Mexico City, Mexico
| | - Eva Juárez-Hernandez
- Translational Research Unit, Medica Sur Clinic & Foundation , Mexico City, Mexico.,Facultad de Ciencias de la Salud, Universidad Anáhuac México , Mexico City, Mexico
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27
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Ichikawa T, Miyaaki H, Miuma S, Motoyoshi Y, Yamashima M, Yamamichi S, Koike M, Takahashi Y, Honda T, Yajima H, Uehara R, Hino N, Hirata R, Taura N, Nakao K. Indices calculated by serum creatinine and cystatin C as predictors of liver damage, muscle strength and sarcopenia in liver disease. Biomed Rep 2020; 12:89-98. [PMID: 32042417 DOI: 10.3892/br.2020.1273] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 10/28/2019] [Indexed: 12/22/2022] Open
Abstract
Serum creatinine (Cr)-based glomerular filtration rate (CrGFR) is overestimated in liver disease. The present study evaluated whether the difference in CrGFR and cystatin C (CysC) GFR (dGFR) is significant in liver disease. The Cr-to-CysC ratio and sarcopenia index (SI) have been reported to correlate with muscle volume. An estimated total body muscle mass with Cr, CysC and calculated body muscle mass (CBMM) has also been reported to correlate with muscle mass. The applicability of dGFR, SI and CBMM for liver disease were evaluated. A total of 313 patients with liver damage were evaluated for Child-Pugh score, albumin-bilirubin (ALBI) score, model for end-stage liver disease, fibrosis-4, Cr, CysC, Cr-based estimated GFR (CreGFR), CysCGFR and grip strength. Of the 313 patients, 199 were evaluated using cross-sectional computed tomography (CT) of the third lumbar vertebra to determine the skeletal muscle (SM) mass. dGFR, CBMM and SI were compared to liver damage, muscle strength and muscle mass. In the 313 patients, dGFR was correlated with age, ALBI and grip strength; CBMM was correlated with body mass index (BMI) and grip strength; and SI was correlated with BMI and grip strength. In patients evaluated with CT, the correlation coefficients for CBMM and SI with SM were 0.804 and 0.293, respectively. Thus, CBMM and SI were associated with sarcopenia. The relationship between dGFR and ALBI does not differ with different grades of CrGFR-based chronic kidney disease (CKD). dGFR is a marker of liver damage and muscle strength regardless of CKD. CBMM and SI are markers for sarcopenia in liver disease.
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Affiliation(s)
- Tatsuki Ichikawa
- Department of Gastroenterology, Nagasaki Harbor Medical Center, Nagasaki 850-8555, Japan.,Innovation and Translational Research Center, Nagasaki Harbor Medical Center, Nagasaki 850-8555, Japan.,Department of Comprehensive Community Care Systems, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
| | - Hisamitsu Miyaaki
- Department of Gastroenterology and Hepatology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
| | - Satoshi Miuma
- Department of Gastroenterology and Hepatology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
| | - Yasuhide Motoyoshi
- Department of Gastroenterology, Nagasaki Harbor Medical Center, Nagasaki 850-8555, Japan
| | - Mio Yamashima
- Department of Gastroenterology, Nagasaki Harbor Medical Center, Nagasaki 850-8555, Japan
| | - Shinobu Yamamichi
- Department of Gastroenterology, Nagasaki Harbor Medical Center, Nagasaki 850-8555, Japan
| | - Makiko Koike
- Innovation and Translational Research Center, Nagasaki Harbor Medical Center, Nagasaki 850-8555, Japan
| | - Youichi Takahashi
- Innovation and Translational Research Center, Nagasaki Harbor Medical Center, Nagasaki 850-8555, Japan
| | - Tetsurou Honda
- Department of Gastroenterology, Nagasaki Harbor Medical Center, Nagasaki 850-8555, Japan
| | - Hiroyuki Yajima
- Department of Gastroenterology, Nagasaki Harbor Medical Center, Nagasaki 850-8555, Japan
| | - Ryouhei Uehara
- Department of Gastroenterology, Nagasaki Harbor Medical Center, Nagasaki 850-8555, Japan
| | - Naoyuki Hino
- Department of Comprehensive Community Care Systems, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan.,Department of Gastroenterology and Hepatology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
| | - Ryousuke Hirata
- Department of Gastroenterology, Nagasaki Harbor Medical Center, Nagasaki 850-8555, Japan
| | - Naota Taura
- Department of Gastroenterology and Hepatology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
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Sarcopenia assessed using bioimpedance analysis is associated independently with significant liver fibrosis in patients with chronic liver diseases. Eur J Gastroenterol Hepatol 2020; 32:58-65. [PMID: 31283527 DOI: 10.1097/meg.0000000000001475] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM Sarcopenia is common in patients with advanced fibrosis or cirrhosis. We investigated the correlation between sarcopenia and other clinical variables, in particular, significant liver fibrosis in patients with chronic liver diseases (CLDs). PATIENTS AND METHODS Patients with CLDs who underwent transient elastography (TE) and bioelectrical impedance analysis between 2015 and 2017 were retrospectively recruited. The sarcopenia index (SI) was calculated as follows: SI = total appendicular skeletal muscle mass (kg)/ body mass index (BMI) (kg/m). Sarcopenia was defined as SI less than 0.789 for men and less than 0.521 for women. Significant liver fibrosis and fatty liver were defined using TE liver stiffness value more than 7 kPa and controlled attenuation parameter more than 250 dB/m, respectively. RESULTS Of 2168 patients recruited, 218 (10.1%) had sarcopenia. Age, BMI, diabetes, hypertension, fasting glucose, aspartate aminotransferase, and liver stiffness value were correlated positively with sarcopenia (all P < 0.05), whereas male sex, viral etiology, obesity (BMI > 25 kg/m), total bilirubin, and serum albumin were correlated negatively with sarcopenia (all P < 0.05). On multivariate analysis, TE-defined significant liver fibrosis was associated independently with sarcopenia (odds ratio = 1.597; 95% confidence interval: 1.174-2.172; P = 0.003), together with age, male sex, viral etiology, and TE-defined fatty liver (all P < 0.05). Among the subgroups with ultrasonography-defined nonalcoholic fatty liver disease (n = 957), sarcopenia was also associated independently with TE-defined significant liver fibrosis (odds ratio = 1.887; 95% confidence interval: 1.261-2.823; P < 0.001). CONCLUSION Sarcopenia is associated independently with significant liver fibrosis in patients with CLDs. Further studies are required to determine whether interventions to improve muscle mass can improve liver fibrosis.
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Circadian rhythm disruption is associated with an increased risk of sarcopenia: a nationwide population-based study in Korea. Sci Rep 2019; 9:12015. [PMID: 31427694 PMCID: PMC6700184 DOI: 10.1038/s41598-019-48161-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 07/29/2019] [Indexed: 12/22/2022] Open
Abstract
Reduced sleep quality is associated with an increased risk of sarcopenia. However, the potential effects of disturbing the regular circadian rhythm, as occurs with shift work, on the risk of sarcopenia have not been established. Data from 9105 workers from the 2008–2011 Korean National Health and Nutrition Examination Survey were analyzed. Sarcopenia, measured by dual-energy X-ray absorptiometry, was defined as one standard deviation below the mean of the appendicular skeletal muscle/body mass index value of a young reference group. Compared to the group that had never experienced shift work, the odds ratio (OR) for sarcopenia with a 95% confidence interval (95% CI) for the shift work group was 1.7 (1.5–1.9); the association remained even after adjusting for confounding variables, including age, sex, total fat mass, insulin resistance profile, smoking, alcohol intake, diet, and physical activity. The results of the subgroup analysis indicated that the highest risk of sarcopenia was among workers engaging in shift work with an irregular schedule (OR 1.8, 95% CI 1.3–2.4). Disruption of circadian rhythm by shift work was associated with increased risk of sarcopenia. Intervention strategies are needed to prevent sarcopenia in shift workers.
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30
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Emerging awareness on the importance of skeletal muscle in liver diseases: time to dig deeper into mechanisms! Clin Sci (Lond) 2019; 133:465-481. [DOI: 10.1042/cs20180421] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/09/2019] [Accepted: 01/23/2019] [Indexed: 02/07/2023]
Abstract
Abstract
Skeletal muscle is a tissue that represents 30–40% of total body mass in healthy humans and contains up to 75% of total body proteins. It is thus the largest organ in non-obese subjects. The past few years have seen increasing awareness of the prognostic value of appreciating changes in skeletal muscle compartment in various chronic diseases. Hence, a low muscle mass, a low muscle function and muscle fatty infiltration are linked with poor outcomes in many pathological conditions. In particular, an affluent body of evidence links the severity, the complications and mortality of chronic liver disease (CLD) with skeletal muscle depletion. Yet it is still not clear whether low muscle mass is a cause, an aggravating factor, a consequence of the ongoing disease, or an epiphenomenon reflecting general alteration in the critically ill patient. The mechanisms by which the muscle compartment influences disease prognosis are still largely unknown. In addition, whether muscle alterations contribute to liver disease progression is an unanswered question. Here, we first review basic knowledge about muscle compartment to draw a conceptual framework for interpreting skeletal muscle alteration in CLD. We next describe recent literature on muscle wasting in cirrhosis and liver transplantation. We then discuss the implication of skeletal muscle compartment in non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH), focusing on plausible metabolic disruption in muscle compartment that might participate in NAFLD progression. Finally, we discuss shortcomings and challenges we need to address in the near future prior to designate the muscle compartment as a therapeutic target in CLD.
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Engelmann C, Schob S, Nonnenmacher I, Werlich L, Aehling N, Ullrich S, Kaiser T, Krohn S, Herber A, Sucher R, Bartels M, Surov A, Hasenclever D, Kahn T, Seehofer D, Moche M, Berg T. Loss of paraspinal muscle mass is a gender-specific consequence of cirrhosis that predicts complications and death. Aliment Pharmacol Ther 2018; 48:1271-1281. [PMID: 30417398 DOI: 10.1111/apt.15026] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/19/2018] [Accepted: 09/28/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Loss of skeletal muscle mass is a recognised complication with a prognostic impact in patients with cirrhosis. AIM To explore in a retrospective analysis which muscle compartment most reliably predicts the occurrence of cirrhosis-associated complications and if there are gender-related differences. METHODS 795 patients with cirrhosis listed for liver transplantation between 2001 and 2014 met the inclusion and exclusion criteria including an abdominal CT scan (±200). Controls were 109 patients who underwent a CT scan after polytrauma. The paraspinal muscles index (PSMI), the abdominal wall muscles index (AWMI) and its combination skeletal muscle index (SMI) were assessed at L3/L4, normalised to the height (cm2 /m2 ). RESULTS 62.0% of patients with cirrhosis had alcoholic liver disease, and 70.6% were male. As compared to controls, a reduction in PSMI and SMI but not AWMI was associated with high model of end-stage liver disease (MELD) score, high Child-Pugh class, and the presence or history of cirrhosis-associated complications in males but not females. PSMI independently predicted the occurrence of bacterial infections (HR 0.932), spontaneous bacterial peritonitis (HR 0.901), hepatic encephalopathy (HR 0.961), and hepatorenal syndrome (HR 0.946) by multivariate Cox regression analysis in a gender-independent manner. Post-transplant survival was not associated with the PSMI; neither AWMI nor SMI predicted any clinical endpoints. CONCLUSIONS This study links muscle wasting in patients with cirrhosis predominantly to males. However, the presence of a low PSMI mass is a gender-independent predictor of developing cirrhosis-associated complications and death. Scores combining the MELD with muscle parameters should be re-validated by utilizing the PSMI.
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Affiliation(s)
- Cornelius Engelmann
- Section Hepatology, Department of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany.,Institute for Liver and Digestive Health, University College London, London, UK
| | - Stefan Schob
- Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Ines Nonnenmacher
- Section Hepatology, Department of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Luise Werlich
- Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Niklas Aehling
- Section Hepatology, Department of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Sebastian Ullrich
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Thorsten Kaiser
- Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Hospital Leipzig, Leipzig, Germany
| | - Sandra Krohn
- Section Hepatology, Department of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Adam Herber
- Section Hepatology, Department of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Robert Sucher
- Department of Visceral, Vascular, Thoracic and Transplant Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Michael Bartels
- Department of Visceral, Vascular, Thoracic and Transplant Surgery, University Hospital Leipzig, Leipzig, Germany.,HELIOS Park Hospital Leipzig, General-, Visceral- and Vascular Surgery, Leipzig, Germany
| | - Alexey Surov
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Dirk Hasenclever
- IMISE - Institute for Medical Informatics, Statistics and Epidemiology, University Leipzig, Leipzig, Germany
| | - Thomas Kahn
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Vascular, Thoracic and Transplant Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Michael Moche
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany.,Diagnostic and Interventional Radiology, Nuernberg, Germany
| | - Thomas Berg
- Section Hepatology, Department of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
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32
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Mudaliar S, Liu K. Editorial: putting more muscle into treating our chronic hepatitis B patients-the importance of assessing sarcopenia. Aliment Pharmacol Ther 2018; 48:579-580. [PMID: 30156323 DOI: 10.1111/apt.14894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- S Mudaliar
- Sydney Medical School, Sydney, NSW, Australia.,Liverpool Hospital, Sydney, NSW, Australia
| | - K Liu
- Sydney Medical School, Sydney, NSW, Australia.,AW Morrow Gastroenterology and Liver Centre, Sydney, NSW, Australia
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