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Hsieh HC, Chang WP, Huang PJ, Wang CH, Lin YH. Effectiveness of Exercise Interventions on Body Composition, Exercise Capacity, Fatigue, and Quality of Life in Patients with Liver Cirrhosis: A Meta-Analysis of Randomized Controlled Trials. Dig Dis Sci 2024; 69:2655-2666. [PMID: 38656415 DOI: 10.1007/s10620-024-08447-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 04/09/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Diminished muscle protein synthesis in cirrhosis leads to reduced strength and mass, impacting daily activities and overall quality of life. AIMS This study aimed to examine the effectiveness of exercise intervention in body composition, exercise capacity, fatigue, and quality of life in patients with liver cirrhosis. METHODS A systematic search of medical databases, including PubMed, Embase, Cochrane, and CINAHL, was executed from their inception to November 2022. The inclusion criteria were randomized controlled trials comparing exercise interventions with a control group that did not receive exercise interventions. RESULTS From the initially identified 2,565 articles, eight studies with a total of 220 patients were eligible for inclusion in this meta-analysis. According to the meta-analysis, exercise significantly improved the six-minute walk distance (6MWD) by 68.93 m (95% CI 14.29-123.57) compared to the control group. Furthermore, the subgroup analysis revealed that combing exercise with amino acid supplementation had a greater positive effect on the 6MWD (MD = 144.72, 95% CI 87.44-202.01). Exercise also significantly increased thigh circumference (MD = 1.26, 95% CI 0.12-2.39) and the thigh ultrasound average compression index (MD = 0.07, 95% CI 0.00-0.14). Moreover, exercise significantly decreased fatigue levels by 0.7 points in patients with liver cirrhosis (95% CI 0.38-1.03). However, no significant effects were observed on body mass index (BMI), fat mass, fat-free mass, and quality of life. CONCLUSIONS Exercise can improve exercise capacity, thigh muscle thickness, and fatigue in patients with cirrhosis, but it does not have a significant impact on fat mass, BMI, or quality of life.
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Affiliation(s)
- Huei-Chi Hsieh
- Department of Nursing, Hsinchu MacKay Memorial Hospital, Hsinchu, Taiwan
| | - Wen-Pei Chang
- Department of Nursing, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Po-Jui Huang
- Division of Gastroenterology, Wan Fang Hospital, Taipei Medical University, Taipei, 110301, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, 250 Wuxing St., Xinyi Dist., Taipei, 11031, Taiwan
| | - Chia-Hui Wang
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Yu-Huei Lin
- Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, 250 Wu-Hsing Street, Taipei, 11031, Taiwan.
- Research Center in Nursing Clinical Practice, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
- Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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Agarwal S, Sharma S, Grover I, Singh N, Ahmed S, Saraya A. Longitudinal changes in bone mineral density may be associated with long-term survival in patients with cirrhosis: A proof of concept of study. Indian J Gastroenterol 2024:10.1007/s12664-023-01504-y. [PMID: 38619809 DOI: 10.1007/s12664-023-01504-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/11/2023] [Indexed: 04/16/2024]
Abstract
INTRODUCTION The impact of longitudinal changes in different body components measured via body composition analysis (BCA) on liver-related outcomes in patients with cirrhosis is poorly understood. We evaluated the prognostic relevance of longitudinal changes in body composition over one year in patients with cirrhosis. METHODS This was a follow-up study of a randomized controlled trial evaluating changes in bone density measured via dual energy X-ray absorptiometry (DEXA) upon vitamin D supplementation. Patients with available anthropometric indices, fat mass (FM), fat-free mass (FFM), bone-density at lumbar spine (LD) and left femur-neck (FD) (assessed by T score) at two time points one year apart were assessed for outcomes. The prognostic relevance of change in parameters such as ΔFM, ΔFFM, ΔLD and ΔFD over one year was assessed and compared with baseline model for end-stage liver disease (MELD) score. RESULTS Patients with cirrhosis (n=112) (mean age 41.8±12 years, 58.5% males) were followed up for median duration of 5.7 years interquartile range [IQR 3.5-5.7], with five-year survival rate of 77%. On serial BCA, ΔLD (p=0.029) and ΔFD (p=0.003) emerged as significant predictors of survival, whereas ΔFM (p=0.479), ΔFFM (p=0.245) and ΔBMI (p=0.949) were not. The area under curve of ΔLD and MELD score for predicting survival was 0.636 (0.5-0.773) and 0.664 (0.555-0.773), respectively. ΔFD<0.1 over one year had sensitivity and specificity of 70.4% and 56.5% to predict poor survival. The combination of ΔFD, MELD and ascites predicted five-year survival with an optimism-corrected c-statistic of 0.785. CONCLUSION Among body composition parameters, changes in bone mineral density correlate best with survival and have prognostic relevance similar to that of ascites and MELD score.
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Affiliation(s)
- Samagra Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Sanchit Sharma
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Indu Grover
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Namrata Singh
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Syed Ahmed
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India.
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Thyloor Kenchappa S, Sharma S, Kumar M, Ghuman SS, Arora A, Ranjan P. A Prospective Study of Prevalence and Impact of Sarcopenia on Short-term Mortality in Hospitalized Patients with Liver Cirrhosis. J Clin Exp Hepatol 2023; 13:946-954. [PMID: 37975055 PMCID: PMC10643475 DOI: 10.1016/j.jceh.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 05/01/2023] [Indexed: 11/19/2023] Open
Abstract
Background Sarcopenia is common in chronic advanced liver disease and is associated with poor prognosis. There is paucity of Indian data regarding sarcopenia in chronic advanced liver disease & its impact on prognosis. The aim of this study was to study the prevalence of sarcopenia in Indian patients with chronic advanced liver disease and its impact on morbidity and short-term mortality. Methods Patients with chronic advanced liver disease were prospectively evaluated for the presence of sarcopenia using computerized tomography (CT) abdomen. The cross-sectional area of the right psoas muscle was measured at the third lumbar vertebra (L3) and the Psoas muscle index (PMI) was calculated. Sarcopenia was defined as PMI <295 mm2/m2 for females and <356 mm2/m2 for males. The normative values of PMI were obtained from patients undergoing CT scan for non-specific abdominal pain who had no confounding factor which could result in sarcopenia. All patients were followed up for 6 months or until death, whichever was earlier. The impact of sarcopenia on mortality and rate of readmission has been assessed at the end of 6 months. Results Of the 156 patients with chronic advanced liver disease, 74 (47.4%) patients had sarcopenia. Sarcopenia was more commonly seen in males (M: F = 61:13) and in patients with alcohol-related liver disease. There was a linear correlation (negative) between the PMI and severity of liver disease as assessed by Child-Pugh and model for end-stage liver disease (MELD) scores (r = -0.591 and -0.465, respectively). Patients with encephalopathy, ascites, and coagulopathy had higher prevalence of sarcopenia. On six months follow-up, sarcopenic patients had higher readmission rates (74.3% vs. 22%; P = 0.0001) and higher mortality (24.3% vs. 3.7%; P = 0.002). MELD score and PMI were independent predictors of mortality. The cut-off value of PMI 305.9 mm2/m2 predicted mortality with a sensitivity of 76.2% and a false positivity of 22.2% (area under curve was 0.805; 95% confidence interval: 0.69-0.91, P = 0.001). Conclusion Sarcopenia is seen in about half of the patients with chronic advanced liver disease. It is commoner in males, patients with alcoholic liver disease, and those with advanced liver disease. Patients with sarcopenia have worse prognosis, require more frequent hospitalization and it negatively impacts short-term survival.
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Affiliation(s)
| | - Samarth Sharma
- Institute of Liver, Gastroenterology, and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Mandhir Kumar
- Institute of Liver, Gastroenterology, and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Anil Arora
- Institute of Liver, Gastroenterology, and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Piyush Ranjan
- Institute of Liver, Gastroenterology, and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
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4
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Kamioka H, Saeki C, Kinoshita A, Nakagawa C, Kanai T, Ueda K, Nakano M, Oikawa T, Torisu Y, Saruta M, Tsubota A. Low geriatric nutritional risk index predicts poor prognosis in patients with cirrhosis: a retrospective study. Front Nutr 2023; 10:1269399. [PMID: 37799767 PMCID: PMC10548194 DOI: 10.3389/fnut.2023.1269399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 09/08/2023] [Indexed: 10/07/2023] Open
Abstract
Aim Malnutrition, which increases the risk of liver disease-related events and mortality, is a serious complication in cirrhosis. This study aimed to investigate whether the geriatric nutritional risk index (GNRI) could predict the long-term prognosis in patients with cirrhosis. Methods We retrospectively evaluated 266 patients with cirrhosis and classified them into two groups based on baseline GNRI scores: risk (≤98, n = 104) and no-risk groups (>98, n = 162). The cumulative survival rates were compared between the two groups in patients with compensated and decompensated cirrhosis, respectively. Cox proportional hazards regression analysis was used to identify significant and independent factors associated with mortality. Results The median observation period was 54.9 (33.6-61.7) months and 65 (24.4%) liver disease-related deaths occurred during the follow-up period. The GNRI scores significantly and inversely correlated with Child-Pugh score (r = -0.579), model for end-stage liver disease score (r = -0.286), and Mac-2 binding protein glycosylation isomer (r = -0.494). Multivariate analysis identified low GNRI as a significant and independent factor associated with mortality [overall cohort: hazard ratio (HR), 0.926; p < 0.001; compensated cirrhosis: HR, 0.947; p = 0.003; decompensated cirrhosis: HR, 0.923; p < 0.001]. The risk group demonstrated significantly lower cumulative survival rates than the no-risk group in overall cohort, and patients with compensated and decompensated cirrhosis (p < 0.001, <0.001, and = 0.013, respectively). Conclusion Low GNRI was associated with poor long-term prognosis in both patients with compensated and decompensated cirrhosis. Therefore, the GNRI is a simple and useful tool for predicting prognosis and modifying the nutritional status in patients with cirrhosis.
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Affiliation(s)
- Hiroshi Kamioka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Chisato Saeki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
- Division of Gastroenterology, Department of Internal Medicine, Fuji City General Hospital, Shizuoka, Japan
| | - Akiyoshi Kinoshita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Chika Nakagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Tomoya Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
- Division of Gastroenterology, Department of Internal Medicine, Fuji City General Hospital, Shizuoka, Japan
| | - Kaoru Ueda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Masanori Nakano
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
- Division of Gastroenterology, Department of Internal Medicine, Fuji City General Hospital, Shizuoka, Japan
| | - Tsunekazu Oikawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuichi Torisu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
- Division of Gastroenterology, Department of Internal Medicine, Fuji City General Hospital, Shizuoka, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Akihito Tsubota
- Project Research Units, Research Center for Medical Science, The Jikei University School of Medicine, Tokyo, Japan
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5
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Gananandan K, Thomas V, Woo WL, Boddu R, Kumar R, Raja M, Balaji A, Kazankov K, Mookerjee RP. Fat mass: a novel digital biomarker for remote monitoring that may indicate risk for malnutrition and new complications in decompensated cirrhosis. BMC Med Inform Decis Mak 2023; 23:180. [PMID: 37705043 PMCID: PMC10498640 DOI: 10.1186/s12911-023-02288-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 09/04/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Cirrhosis is associated with sarcopaenia and fat wasting, which drive decompensation and mortality. Currently, nutritional status, through body composition assessment, is not routinely monitored in outpatients. Given the deleterious outcomes associated with poor nutrition in decompensated cirrhosis, there is a need for remotely monitoring this to optimise community care. METHODS A retrospective analysis was conducted on patients monitored remotely with digital sensors post hospital discharge, to assess outcomes and indicators of new cirrhosis complications. 15 patients had daily fat mass measurements as part of monitoring over a median 10 weeks, using a Withing's bioimpedance scale. The Clinical Frailty Score (CFS) was used to assess frailty and several liver disease severity scores were assessed. RESULTS 73.3% (11/15) patients were male with a median age of 63 (52-68). There was a trend towards more severe liver disease based on CLIF-Consortium Acute Decompensation (CLIF-C AD) scores in frail patients vs. those not frail (53 vs 46, p = 0.072). When the cohort was split into patients who gained fat mass over 8 weeks vs. those that lost fat mass, the baseline CLIF-C AD scores and WBC were significantly higher in those that lost fat (58 vs 48, p = 0.048 and 11.2 × 109 vs 4.7 × 109, p = 0.031). CONCLUSIONS This proof-of-principle study shows feasibility for remote monitoring of fat mass and nutritional reserve in decompensated cirrhosis. Our results suggest fat mass is associated with greater severity of acute decompensation and may serve as an indicator of systemic inflammatory response. Further prospective studies are required to validate this digital biomarker.
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Affiliation(s)
- K Gananandan
- Institute for Liver and Digestive Health, University College London, London, UK.
| | - V Thomas
- Institute for Liver and Digestive Health, University College London, London, UK
| | - W L Woo
- Royal Free Hospital, London, UK
| | - R Boddu
- CyberLiver Limited, London, UK
| | - R Kumar
- CyberLiver Limited, London, UK
| | - M Raja
- CyberLiver Limited, London, UK
| | | | - K Kazankov
- Institute for Liver and Digestive Health, University College London, London, UK
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - R P Mookerjee
- Institute for Liver and Digestive Health, University College London, London, UK
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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6
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Espinosa-Flores AJ, Guzman-Ortiz E, Melendez-Mier G, Ternovoy SK, Bueno-Hernandez N, Roldan-Valadez E. A scoping review of the methods used in patients with liver cirrhosis to assess body composition and their nutritional findings. Eur J Clin Nutr 2023; 77:845-854. [PMID: 37095222 DOI: 10.1038/s41430-023-01287-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/07/2023] [Accepted: 04/13/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND AND OBJECTIVES Body composition (BC) assessment in cirrhosis has a wide variety of methods with no consensus on the best tools for each body component in patients with Liver Cirrhosis (LC). We aimed to conduct a systematic scoping review of the most frequent body composition analysis methods and nutritional findings published in liver cirrhosis patients. METHODS We searched for articles in PubMed, Scopus, and ISI Web of Science databases. Keywords selected the BC methods and parameters in LC. RESULTS Eleven methods were found. The most frequently used were computed tomography (CT) 47.5%, Bioimpedance Analysis 35%, DXA 32.5%, and anthropometry 32.5%. Up to 15 BC parameters were reported from each method. CONCLUSIONS The vast heterogeneity in the results found during the qualitative analysis and imaging methods must reach a consensus to achieve a better clinical practice and improve nutritional treatment, as the physiopathology in LC compromises the nutritional status directly.
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Affiliation(s)
- Aranza-Jhosadara Espinosa-Flores
- Laboratory for Proteomics and Metabolomics, Research Division, Hospital General de Mexico "Dr Eduardo Liceaga,", 06720, Mexico City, Mexico
| | - Elizabeth Guzman-Ortiz
- Department of Nursing and Obstetrics, Universidad de Guanajuato, 36000, Celaya City, Mexico
| | | | - Sergey K Ternovoy
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, 127005, Moscow, Russia
| | - Nallely Bueno-Hernandez
- Laboratory for Proteomics and Metabolomics, Research Division, Hospital General de Mexico "Dr Eduardo Liceaga,", 06720, Mexico City, Mexico.
| | - Ernesto Roldan-Valadez
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia.
- Directorate of Research, Hospital General de Mexico "Dr Eduardo Liceaga", 06720, Mexico City, Mexico.
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Kumar R, Prakash SS, Priyadarshi RN, Anand U. Sarcopenia in Chronic Liver Disease: A Metabolic Perspective. J Clin Transl Hepatol 2022; 10:1213-1222. [PMID: 36381104 PMCID: PMC9634780 DOI: 10.14218/jcth.2022.00239] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/14/2022] [Accepted: 07/19/2022] [Indexed: 12/04/2022] Open
Abstract
Sarcopenia, a condition of low muscle mass, quality, and strength, is commonly found in patients with chronic liver disease (CLD) and is associated with adverse clinical outcomes including reduction in quality of life, increased mortality, and complications. A major contributor to sarcopenia in CLD is the imbalance in muscle protein turnover wherein changes in various metabolic factors such as hyperammonemia, amino acid deprivation, hormonal imbalance, gut dysbiosis, insulin resistance, chronic inflammation, etc. have important roles. In particular, hyperammonemia is a key mediator of the liver-gut axis and is known to contribute to sarcopenia by various mechanisms including increased expression of myostatin, increased phosphorylation of eukaryotic initiation factor 2a, cataplerosis of α-ketoglutarate, mitochondrial dysfunction, increased reactive oxygen species that decrease protein synthesis and increased autophagy-mediated proteolysis. Skeletal muscle is a major organ of insulin-induced glucose metabolism, and sarcopenia is closely linked to insulin resistance and metabolic syndrome. Patients with liver cirrhosis are in a hypermetabolic state that is associated with catabolism and depletion of amino acids, particularly branched-chain amino acids. Sarcopenia can have significant implications for nonalcoholic fatty liver disease, the most common form of CLD worldwide, because of the close link between metabolic syndrome and sarcopenia. This review discusses the potential metabolic derangement as a cause or effect of sarcopenia in CLD, as well as interorgan crosstalk, which that might help identifying a novel therapeutic strategies.
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, India
- Correspondence to: Ramesh Kumar, Department of Gastroenterology, fourth floor, OPD Block, All India Institute of Medical Sciences, Patna 801507, India. ORCID: https://orcid.org/0000-0001-5136-4865. Tel: +91-7765803112, Fax: +91-11-26588663, E-mail:
| | - Sabbu Surya Prakash
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | | | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
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Bischoff SC, Barazzoni R, Busetto L, Campmans-Kuijpers M, Cardinale V, Chermesh I, Eshraghian A, Kani HT, Khannoussi W, Lacaze L, Léon-Sanz M, Mendive JM, Müller MW, Ockenga J, Tacke F, Thorell A, Vranesic Bender D, Weimann A, Cuerda C. European guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline. Clin Nutr 2022; 41:2364-2405. [PMID: 35970666 DOI: 10.1016/j.clnu.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/03/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with chronic gastrointestinal (GI) disease such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, gastroesophageal reflux disease (GERD), pancreatitis, and chronic liver disease (CLD) often suffer from obesity because of coincidence (IBD, IBS, celiac disease) or related pathophysiology (GERD, pancreatitis and CLD). It is unclear if such patients need a particular diagnostic and treatment that differs from the needs of lean GI patients. The present guideline addresses this question according to current knowledge and evidence. OBJECTIVE The objective of the guideline is to give advice to all professionals working in the field of gastroenterology care including physicians, surgeons, dietitians and others how to handle patients with GI disease and obesity. METHODS The present guideline was developed according to the standard operating procedure for ESPEN guidelines, following the Scottish Intercollegiate Guidelines Network (SIGN) grading system (A, B, 0, and good practice point (GPP)). The procedure included an online voting (Delphi) and a final consensus conference. RESULTS In 100 recommendations (3x A, 33x B, 24x 0, 40x GPP, all with a consensus grade of 90% or more) care of GI patients with obesity - including sarcopenic obesity - is addressed in a multidisciplinary way. A particular emphasis is on CLD, especially fatty liver disease, since such diseases are closely related to obesity, whereas liver cirrhosis is rather associated with sarcopenic obesity. A special chapter is dedicated to obesity care in patients undergoing bariatric surgery. The guideline focuses on adults, not on children, for whom data are scarce. Whether some of the recommendations apply to children must be left to the judgment of the experienced pediatrician. CONCLUSION The present guideline offers for the first time evidence-based advice how to care for patients with chronic GI diseases and concomitant obesity, an increasingly frequent constellation in clinical practice.
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Affiliation(s)
- Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany.
| | - Rocco Barazzoni
- Department of Medical, Technological and Translational Sciences, University of Trieste, Ospedale di Cattinara, Trieste, Italy.
| | - Luca Busetto
- Department of Medicine, University of Padova, Padova, Italy.
| | - Marjo Campmans-Kuijpers
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, the Netherlands.
| | - Vincenzo Cardinale
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy.
| | - Irit Chermesh
- Department of Gastroenterology, Rambam Health Care Campus, Affiliated with Technion-Israel Institute of Technology, Haifa, Israel.
| | - Ahad Eshraghian
- Department of Gastroenterology and Hepatology, Avicenna Hospital, Shiraz, Iran.
| | - Haluk Tarik Kani
- Department of Gastroenterology, Marmara University, School of Medicine, Istanbul, Turkey.
| | - Wafaa Khannoussi
- Hepato-Gastroenterology Department, Mohammed VI University Hospital, Oujda, Morocco; Laboratoire de Recherche des Maladies Digestives (LARMAD), Mohammed the First University, Oujda, Morocco.
| | - Laurence Lacaze
- Department of General Surgery, Mantes-la-Jolie Hospital, Mantes-la-Jolie, France; Department of Clinical Nutrition, Paul-Brousse-Hospital, Villejuif, France.
| | - Miguel Léon-Sanz
- Department of Endocrinology and Nutrition, University Hospital Doce de Octubre, Medical School, University Complutense, Madrid, Spain.
| | - Juan M Mendive
- La Mina Primary Care Academic Health Centre, Catalan Institute of Health (ICS), University of Barcelona, Barcelona, Spain.
| | - Michael W Müller
- Department of General and Visceral Surgery, Regionale Kliniken Holding, Kliniken Ludwigsburg-Bietigheim GGmbH, Krankenhaus Bietigheim, Bietigheim-Bissingen, Germany.
| | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen-Mitte, Bremen FRG, Bremen, Germany.
| | - Frank Tacke
- Department of Hepatology & Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany.
| | - Anders Thorell
- Department of Clinical Science, Danderyds Hospital, Karolinska Institutet & Department of Surgery, Ersta Hospital, Stockholm, Sweden.
| | - Darija Vranesic Bender
- Unit of Clinical Nutrition, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany.
| | - Cristina Cuerda
- Departamento de Medicina, Universidad Complutense de Madrid, Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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Engelmann C, Aehling NF, Schob S, Nonnenmacher I, Handmann L, Macnaughtan J, Herber A, Surov A, Kaiser T, Denecke T, Jalan R, Seehofer D, Moche M, Berg T. Body fat composition determines outcomes before and after liver transplantation in patients with cirrhosis. Hepatol Commun 2022; 6:2198-2209. [PMID: 35420246 PMCID: PMC9315113 DOI: 10.1002/hep4.1946] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/24/2022] [Accepted: 02/17/2022] [Indexed: 11/25/2022] Open
Abstract
Cachexia occurs in late stages of liver cirrhosis, and a low-fat mass is potentially associated with poor outcome. This study compared different computed tomography (CT)-derived fat parameters with respect to its prognostic impact on the development of complications and death before and after liver transplantation. Between 2001 and 2014, 612 patients with liver cirrhosis without hepatocellular carcinoma listed for liver transplantation met the inclusion criteria, including abdominal CT scan (±200 days to listing). A total of 109 patients without cirrhosis served as controls. The subcutaneous fat index (SCFI), the paraspinal muscle fat index, and the visceral fat index were assessed at L3/L4 level and normalized to the height (cm2 /m2 ). Data were collected and analyzed retrospectively. Low SCFI was associated with a higher rate of ascites and increased C-reactive protein levels (p < 0.001). In addition, multivariate Cox regression analysis adjusting for sex, age, body mass index (BMI), and Model for End-Stage Liver Disease showed that decreasing SCFI was also associated with an increased risk of cirrhosis-related complications (p = 0.003) and death on the transplant wait list (p = 0.013). Increased paraspinal and visceral fat were not only positively correlated with creatinine levels (p < 0.001), BMI, and metabolic comorbidities (all p < 0.001) before transplantation, but also predictive for 1-year mortality after transplantation. Conclusion: The distribution of body fat is a major determinant for complications and outcome in cirrhosis before and after liver transplantation.
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Affiliation(s)
- Cornelius Engelmann
- Division of HepatologyDepartment of Medicine IILeipzig University Medical CenterLeipzigGermany.,Liver Failure GroupInstitute for Liver and Digestive HealthUniversity College LondonRoyal Free CampusLondonUK.,Department of Hepatology and GastroenterologyCampus Virchow-KlinikumCharité-Universitaetsmedizin BerlinBerlinGermany.,522475Berlin Institute of HealthBerlinGermany
| | - Niklas F Aehling
- Division of HepatologyDepartment of Medicine IILeipzig University Medical CenterLeipzigGermany
| | - Stefan Schob
- Department for NeuroradiologyUniversity Hospital LeipzigLeipzigGermany
| | - Ines Nonnenmacher
- Division of HepatologyDepartment of Medicine IILeipzig University Medical CenterLeipzigGermany
| | - Luise Handmann
- Division of HepatologyDepartment of Medicine IILeipzig University Medical CenterLeipzigGermany
| | - Jane Macnaughtan
- Liver Failure GroupInstitute for Liver and Digestive HealthUniversity College LondonRoyal Free CampusLondonUK
| | - Adam Herber
- Division of HepatologyDepartment of Medicine IILeipzig University Medical CenterLeipzigGermany
| | - Alexey Surov
- Department of Diagnostic and Interventional RadiologyUniversity Hospital LeipzigLeipzigGermany
| | - Thorsten Kaiser
- Institute of Laboratory Medicine, Clinical Chemistry and Molecular DiagnosticsUniversity Hospital LeipzigLeipzigGermany
| | - Timm Denecke
- Department of Diagnostic and Interventional RadiologyUniversity Hospital LeipzigLeipzigGermany
| | - Rajiv Jalan
- Liver Failure GroupInstitute for Liver and Digestive HealthUniversity College LondonRoyal Free CampusLondonUK
| | - Daniel Seehofer
- Department of VisceralVascularThoracic and Transplant SurgeryUniversity Hospital LeipzigLeipzigGermany
| | - Michael Moche
- Department of Diagnostic and Interventional RadiologyUniversity Hospital LeipzigLeipzigGermany.,Diagnostic and Interventional RadiologyPark Hospital LeipzigLeipzigGermany
| | - Thomas Berg
- Division of HepatologyDepartment of Medicine IILeipzig University Medical CenterLeipzigGermany
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10
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Randomized Clinical Trial: Effects of β-Hydroxy-β-Methylbutyrate (HMB)-Enriched vs. HMB-Free Oral Nutritional Supplementation in Malnourished Cirrhotic Patients. Nutrients 2022; 14:nu14112344. [PMID: 35684144 PMCID: PMC9183090 DOI: 10.3390/nu14112344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 11/17/2022] Open
Abstract
β-Hydroxy-β-methylbutyrate (HMB) supplementation increases muscle and strength mass in some muscle-wasting disorders. Malnutrition and sarcopenia are often present in liver cirrhosis. We aimed to investigate the effects of oral HMB supplementation on changes in body composition and liver status in patients with cirrhosis and malnutrition. In a randomized, controlled, double-blind trial, 43 individuals were randomized to receive twice a day and for 12 weeks an oral nutritional supplement (ONS) enriched with 1.5 g of calcium HMB per bottle or another supplement with similar composition devoid of HMB. Inclusion criteria were liver cirrhosis with at least one previous decompensation and clinical malnutrition. Liver function, plasma biochemistry analyses, and physical condition assessment were carried out at baseline, then after six and 12 weeks of supplementation. A total of 34 patients completed the clinical trial. An improvement in liver function and an increase in fat mass index were observed in both groups. None of the two ONS changed the fat-free mass. However, we observed an upward trend in handgrip strength and a downward trend in minimal hepatic encephalopathy in the HMB group. At the end of the trial and regardless of the supplement administered, fat mass content increased with no change in fat-free mass, while liver function scores and nutritional analytic markers also improved.
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11
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Faccioli J, Nardelli S, Gioia S, Riggio O, Ridola L. Nutrition Assessment and Management in Patients with Cirrhosis and Cognitive Impairment: A Comprehensive Review of Literature. J Clin Med 2022; 11:jcm11102842. [PMID: 35628968 PMCID: PMC9147845 DOI: 10.3390/jcm11102842] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/16/2022] [Indexed: 02/01/2023] Open
Abstract
Hepatic encephalopathy (HE) represents a common complication of liver cirrhosis. Protein-calorie malnutrition is frequently encountered in the cirrhotic patient and its most obvious clinical manifestation is sarcopenia. This condition represents a risk factor for HE occurrence because skeletal muscle acts as an alternative site for ammonium detoxification. Preventive intervention through an adequate assessment of nutritional status should be carried out at early stages of the disease and in a multidisciplinary team using both non-instrumental methods (food diary, anthropometric measurements, blood chemistry tests) and instrumental methods (bioimpedance testing, DEXA, CT, indirect calorimetry, dynamometry). Dietary recommendations for patients with HE do not differ from those for cirrhotic patient without HE. Daily caloric intake in the non-obese patient should be 30–40 Kcal/Kg/day with a protein intake of 1–1.5 g/Kg/day, especially of vegetable origin, through 4–6 meals daily. In patients with HE, it is also essential to monitor electrolyte balance, supplementing any micronutrient deficiencies such as sodium and zinc, as well as vitamin deficiencies because they can cause neurological symptoms similar to those of HE. In light of the critical role of nutritional status, this aspect should not be underestimated and should be included in the diagnostic–therapeutic algorithm of patients with HE.
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12
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Cho YS, Lee HY, Jeong JY, Lee JG, Kim TY, Nam SW, Sohn JH. Computed Tomography-Determined Body Composition Abnormalities Usefully Predict Long-term Mortality in Patients With Liver Cirrhosis. J Comput Assist Tomogr 2021; 45:684-690. [PMID: 34407059 DOI: 10.1097/rct.0000000000001207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE We evaluated the prognostic impacts of body composition components measured by computed tomography (CT) in patients with liver cirrhosis. METHODS A total of 160 cirrhotic patients who underwent CT and hepatic venous pressure gradient measurements were retrospectively enrolled. Cross-sectional areas of skeletal muscle, visceral and subcutaneous fat, and mean CT attenuation of trabecular bone of the fourth lumbar vertebral level (L4HU) were measured. RESULTS Multivariate analysis showed model for end-stage liver disease score [hazard ratio (HR), 1.086; 95% confidence interval (CI), 1.020-1.156; P = 0.010], hepatic venous pressure gradient (HR, 1.076; 95% CI, 1.021-1.135; P = 0.006), sarcopenia (HR, 1.890; 95% CI, 1.032-3.462; P = 0.039), and L4HU (HR, 1.960 for L4HU <145 Hounsfield units; 95% CI, 1.094-3.512; P = 0.024) were independently associated with long-term mortality. In patients with decompensated cirrhosis, subcutaneous adipose tissue index was the only independent predictor (HR, 0.984; 95% CI, 0.969-0.999; P = 0.039). CONCLUSION Body composition abnormalities determined by CT are associated with long-term prognosis in cirrhotic patients.
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Affiliation(s)
- Young Seo Cho
- From the Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri
| | - Ha Young Lee
- Department of Radiology, Inha University School of Medicine, Incheon
| | | | - Jae Gon Lee
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri
| | - Tae Yeob Kim
- Department of Internal Medicine, New Hope Internal Medicine Clinic, Seoul, Korea
| | - Seong Woo Nam
- Department of Internal Medicine, National Medical Center, Seoul
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri
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13
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Kyrana E. Significance of sarcopenia in children with end-stage liver disease undergoing liver transplantation. Pediatr Transplant 2021; 25:e14038. [PMID: 34120403 DOI: 10.1111/petr.14038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 04/12/2021] [Accepted: 04/16/2021] [Indexed: 12/28/2022]
Affiliation(s)
- Eirini Kyrana
- Paediatric Liver, GI, and Nutrition Centre, King's College Hospital, London, UK
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14
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Alsmadi MM, Al-Daoud NM, Jaradat MM, Alzughoul SB, Abu Kwiak AD, Abu Laila SS, Abu Shameh AJ, Alhazabreh MK, Jaber SA, Abu Kassab HT. Physiologically-based pharmacokinetic model for alectinib, ruxolitinib, and panobinostat in the presence of cancer, renal impairment, and hepatic impairment. Biopharm Drug Dispos 2021; 42:263-284. [PMID: 33904202 DOI: 10.1002/bdd.2282] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 03/18/2021] [Accepted: 04/11/2021] [Indexed: 12/24/2022]
Abstract
Renal (RIP) and hepatic (HIP) impairments are prevalent conditions in cancer patients. They can cause changes in gastric emptying time, albumin levels, hematocrit, glomerular filtration rate, hepatic functional volume, blood flow rates, and metabolic activity that can modify drug pharmacokinetics. Performing clinical studies in such populations has ethical and practical issues. Using predictive physiologically-based pharmacokinetic (PBPK) models in the evaluation of the PK of alectinib, ruxolitinib, and panobinostat exposures in the presence of cancer, RIP, and HIP can help in using optimal doses with lower toxicity in these populations. Verified PBPK models were customized under scrutiny to account for the pathophysiological changes induced in these diseases. The PBPK model-predicted plasma exposures in patients with different health conditions within average 2-fold error. The PBPK model predicted an area under the curve ratio (AUCR) of 1, and 1.8, for ruxolitinib and panobinostat, respectively, in the presence of severe RIP. On the other hand, the severe HIP was associated with AUCR of 1.4, 2.9, and 1.8 for alectinib, ruxolitinib, and panobinostat, respectively, in agreement with the observed AUCR. Moreover, the PBPK model predicted that alectinib therapeutic cerebrospinal fluid levels are achieved in patients with non-small cell lung cancer, moderate HIP, and severe HIP at 1-, 1.5-, and 1.8-fold that of healthy subjects. The customized PBPK models showed promising ethical alternatives for simulating clinical studies in patients with cancer, RIP, and HIP. More work is needed to quantify other pathophysiological changes induced by simultaneous affliction by cancer and RIP or HIP.
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Affiliation(s)
- Mo'tasem M Alsmadi
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Nour M Al-Daoud
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Mays M Jaradat
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Saja B Alzughoul
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Amani D Abu Kwiak
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Salam S Abu Laila
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Ayat J Abu Shameh
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Mohammad K Alhazabreh
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Sana'a A Jaber
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Hala T Abu Kassab
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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15
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Shin S, Jun DW, Saeed WK, Koh DH. A narrative review of malnutrition in chronic liver disease. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:172. [PMID: 33569474 PMCID: PMC7867872 DOI: 10.21037/atm-20-4868] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Interest in research on malnutrition is decreasing due to thoughts that the problem of malnutrition has been solved in an age of over-nourishment or obesity and defining malnutrition is not uniform. This study aimed to critically appraise the prevalence of malnutrition according to various diagnostic tools and proportion of severity used in previous studies. A literature review was performed using a total of 16 studies published between 1980 and 2020 regarding malnutrition in patients with chronic liver disease. Most of the analyzed studies were conducted before 2010, and only a few studies were conducted after 2010. Nutrition assessment tool (NAT) and nutrition screening tool (NST) to explain malnutrition were distinguished; however, there was no clear distinction between them. NST often used questionnaires while NST used various malnutrition measuring tools. Our results show that, in the age of over-nourishment, reduction in malnutrition in chronic liver disease still hasn’t been significant. Malnutrition prevalence in studies published prior to 2,000 ranged between 13.3% and 85% (mean, 37.6%), whereas that in studies published after 2,000 ranged between 13.3% and 78.5% (mean, 35.2%). Malnutrition prevalence largely depends on the diagnostic tool and proportion of disease severity in the target population. The prevalence of malnutrition in patients with chronic liver diseases varies widely. This big difference is related to various diagnostic tools, mixed etiologies, and different disease severity in different studies. The prevalence of malnutrition was 36.4% (10–80.3%) in all patients with liver disease, 39.9% (13.3–80.3%) in compensated liver disease, and 44.1% (26.7–93.6%) in decompensated cirrhosis. Malnutrition prevalence was 38.2% and 23.7% in alcoholism-related and hepatitis C virus (HCV)-related diseases, respectively. Malnutrition also largely depended on the judgement tool. Malnutrition prevalence according to the diagnostic tool was approximately 28–85% for subjective global assessment (SGA), 30.8–78.5% for anthropometric approach, and 21–80.3% for clinical judgment. It became similar over time.
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Affiliation(s)
- Soan Shin
- School of Medicine, Hanyang University, Seoul, South Korea
| | - Dae Won Jun
- School of Medicine, Hanyang University, Seoul, South Korea.,Department of Internal Medicine, School of Medicine, Hanyang University, Seoul, South Korea
| | - Waqar Khalid Saeed
- Department of Biomedical Sciences, Pak-Austria Fachhochschule: Institute of Applied Sciences and Technology, Mang, Haripur, Pakistan
| | - Dong Hee Koh
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si, South Korea
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16
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Ebadi M, Bhanji RA, Tandon P, Mazurak V, Baracos VE, Montano-Loza AJ. Review article: prognostic significance of body composition abnormalities in patients with cirrhosis. Aliment Pharmacol Ther 2020; 52:600-618. [PMID: 32621329 DOI: 10.1111/apt.15927] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/17/2020] [Accepted: 06/09/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recent advances in evaluation of body composition show body mass index to be inadequate in differentiating between body compartments in cirrhosis. Given the limitations of body mass index, body composition evaluation using computed tomography has been increasingly used as a non-invasive clinical tool with prognostic value. Another factor influencing prognosis includes sex-specific differences in body composition that are seen in cirrhosis. AIM To review current knowledge regarding the frequency and clinical implications of abnormal body composition features in cirrhosis. METHODS We searched PubMed database and limited the literature search to full-text papers published in English. Studies using inappropriate landmarks or demarcation of body composition components on computed tomography images were eliminated. RESULTS Sarcopenia is a well established factor affecting morbidity and mortality in cirrhosis. Other important body composition components that have been overlooked thus far include subcutaneous adipose tissue and visceral adipose tissue. Female patients with cirrhosis and low subcutaneous adiposity have a higher risk of mortality, whereas male patients with high visceral adiposity have a higher risk of hepatocellular carcinoma and recurrence following liver transplantation. Increased adipose tissue radiodensity has been associated with risk of decompensation and mortality. CONCLUSIONS Further evaluation of body composition abnormalities may help with development of targeted therapeutic strategies and improve outcome in patients with cirrhosis. Moreover, recognition of these abnormalities could improve prioritisation for liver transplantation as our current method based solely on liver function might lead to risk misclassification.
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Affiliation(s)
- Maryam Ebadi
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, AB, Canada
| | - Rahima A Bhanji
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, AB, Canada
| | - Puneeta Tandon
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, AB, Canada
| | - Vera Mazurak
- Division of Human Nutrition, University of Alberta, Edmonton, AB, Canada
| | - Vickie E Baracos
- Department of Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Aldo J Montano-Loza
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, AB, Canada
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17
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Resting Energy Expenditure of Children With End-stage Chronic Liver Disease Before and After Liver Transplantation. J Pediatr Gastroenterol Nutr 2019; 69:102-107. [PMID: 30908388 DOI: 10.1097/mpg.0000000000002344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Our objective was to test the hypothesis that children with end-stage chronic liver disease (ESCLD) are hypermetabolic when compared to healthy children, and that this hypermetabolism persists for at least 6 months after liver transplant. METHODS Seventeen patients with end-stage chronic liver disease and 14 healthy controls had their resting energy expenditure measured (mREE) by indirect calorimetry. Weight, height, and body mass index were converted to standard deviation (SD) scores. Children older than 5 years had air displacement plethysmography and patients older than 5 years also had whole body dual-energy X-ray absorptiometry with characterization of fat mass (FM), fat-free mass (FFM), and bone-free fat free (lean) mass. RESULTS When compared to the prediction equation 44% of the patients and 50% of the healthy controls were hypermetabolic. The younger patients (0-5 years) had a lower mREE than the healthy controls but were significantly lighter and shorter than their healthy counterparts. mREE correlated strongly for all children with age, weight, height, and FFM. There was a strong negative correlation between age and mREE/kg in both patients (rs = -0.94, P < 0.01) and controls (rs = -0.91, P < 0.01). Almost 84% of the variance in mREE was explained by age (P < 0.001). There were no significant differences between resting energy expenditure (REE)/FFM between the 2 groups. mREE/kg before liver transplant correlated with mREE/kg after transplant (Pearson r = 0.83, P < 0.01). CONCLUSIONS REE mostly reflected the size of the child. The patients were not hypermetabolic when compared to the healthy children. The main determinant of REE/kg after transplant was REE/kg before transplant.
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18
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Ruiz-Margáin A, Méndez-Guerrero O, Román-Calleja BM, González-Rodríguez S, Fernández-Del-Rivero G, Rodríguez-Córdova PA, Torre A, Macías-Rodríguez RU. Dietary management and supplementation with branched-chain amino acids in cirrhosis of the liver. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018; 83:424-433. [PMID: 30292583 DOI: 10.1016/j.rgmx.2018.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/17/2018] [Accepted: 05/21/2018] [Indexed: 12/12/2022]
Abstract
One of the most important characteristics of malnutrition is the loss of muscle mass and the severe depletion of the protein reserve, secondarily affecting energy metabolism. That impacts nutritional status and the progression of disease-related complications. Nutritional treatment is one of the main factors in the comprehensive management of those patients. Achieving adequate energy intake that provides the macronutrients and micronutrients necessary to prevent or correct malnutrition is attempted through dietary measures. ESPEN, the European Society for Clinical Nutrition and Metabolism, recommends a caloric intake of 30-40kcal/kg/day, in which carbohydrates provide 45-60% of the daily energy intake and proteins supply 1.0-1.5g/kg/day. The remaining portion of the total energy expenditure should be covered by lipids. The administration of branched-chain amino acids has been shown to be beneficial not only in counteracting malnutrition, but also as a coadjuvant treatment in specific complications, thus playing a favorable role in outcome and quality of life. Therefore, branched-chain amino acids should be considered part of nutritional treatment in patients with advanced stages of cirrhosis of the liver, particularly in the presence of complications.
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Affiliation(s)
- A Ruiz-Margáin
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
| | - O Méndez-Guerrero
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - B M Román-Calleja
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - S González-Rodríguez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - G Fernández-Del-Rivero
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - P A Rodríguez-Córdova
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - A Torre
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - R U Macías-Rodríguez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
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19
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Dietary management and supplementation with branched-chain amino acids in cirrhosis of the liver. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2018.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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20
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Abstract
Liver cirrhosis is associated with significant nutritional risks that often result in serious hepatic complications and poor survival rates. Diet is an important but underutilized aspect in the treatment modality of cirrhosis. Therefore, the aims of this review are to ascertain nutritional risks associated with its pathophysiology and to summarize existing evidence that support dietary recommendations for managing this patient population. Alterations in substrate utilization for energy production is a main feature of liver cirrhosis, resulting in increased catabolism of protein stores and a predisposition toward protein-energy malnutrition, even in the early stages of the disease. The body of evidence suggests that a high energy and protein (>1.2 g/kg body weight/d) diet consumed frequently and late in the evening is effective in improving nutritional status of these patients and has been associated with improved hospitalization and mortality rates. The use of branched-chain amino acid supplementation shows promise in reducing cirrhosis-related complications but are currently limited by adverse gastrointestinal symptoms and poor palatability. Furthermore exploration of dietary manipulation of branched-chain amino acid warrants further examination. Evidence is also accumulating that protein intake should not be restricted in patients with hepatic encephalopathy with earlier studies of protein restriction neglecting to account for the relative increase in fermentable fiber which would reduce the absorption of ammonia into the portal system in a way similar to supplementation with lactulose. Finally, a major finding of this review is the need to improve the quality and quantity of dietary intervention studies for patients with liver cirrhosis, particularly with the use of partial or whole dietary sources. In conclusion, dietary management of cirrhosis is not a one-size fits all approach but should be implemented earlier on in the treatment algorithm to improve the clinical prognosis of cirrhosis.
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Abstract
As the cirrhosis progresses, development of complication like ascites, hepatic encephalopathy, variceal bleeding, kidney dysfunction, and hepatocellular carcinoma signify increasing risk of short term mortality. Malnutrition and muscle wasting (sarcopenia) is yet other complications that negatively impact survival, quality of life, and response to stressors, such as infection and surgery in patients with cirrhosis. Conventionally, these are not routinely looked for, because nutritional assessment can be a difficult especially if there is associated fluid retention and/or obesity. Patients with cirrhosis may have a combination of loss of skeletal muscle and gain of adipose tissue, culminating in the condition of "sarcopenic obesity." Sarcopenia in cirrhotic patients has been associated with increased mortality, sepsis complications, hyperammonemia, overt hepatic encephalopathy, and increased length of stay after liver transplantation. Assessment of muscles with cross-sectional imaging studies has become an attractive index of nutritional status evaluation in cirrhosis, as sarcopenia, the major component of malnutrition, is primarily responsible for the adverse clinical consequences seen in patients with liver disease. Cirrhosis is a state of accelerated starvation, with increased gluconeogenesis that requires amino acid diversion from other metabolic functions. Protein homeostasis is disturbed in cirrhosis due to several factors such as hyperammonemia, hormonal, and cytokine abnormalities, physical inactivity and direct effects of ethanol and its metabolites. New approaches to manage sarcopenia are being evolved. Branched chain amino acid supplementation, Myostatin inhibitors, and mitochondrial protective agents are currently in various stages of evaluation in preclinical studies to prevent and reverse sarcopenia, in cirrhosis.
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Key Words
- (PG) SGA, patient-generated SGA
- AMPK, 5′ adenosine monophosphate-activated protein kinase
- ASPEN, American Society of Parenteral and Enteral Nutrition
- ATP, adenosine triphosphate
- Akt/PKB, serine/threonine-specific protein kinase B
- BIA, bio-electric impedance analysis
- BMC, bone mineral content
- BMI, body mass index
- CT, computed tomography
- DDLT, deceased donor liver transplantation
- DRM, disease-related malnutrition
- DXA, dual X-ray absorptiometry
- ESPEN, European Society of Parenteral and Enteral Nutrition
- FFI, Fried Frailty Index
- FFM, fat free mass
- FFMI, fat free mass index
- FM, fat mass
- HE, hepatic encephalopathy
- LDLT, living donor liver transplant
- LST, lean soft tissue
- MAC, mid arm circumference
- MAMC, mid arm muscle circumference
- MELD, model for end-stage liver disease
- MNA, Mini Nutritional Assessment
- MRI, magnetic resonance imaging
- NASH, non-alcoholic steatohepatitis
- PCM, protein-calorie nalnutrition
- REE, resting energy expenditure
- RQ, respiratory quotient (or RQ or respiratory coefficient)
- SGA, Subjective Global Assessment
- SMI, Skeletal Muscle Index
- SPPB, Short Physical Performance Battery
- TIPS, trans jugular intrahepatic portocaval shunts
- TNF, tumour necrosis factor
- TSF, triceps skin fild thickness
- WHO, World Health Organisation
- YPA, total psoas area
- aKG, alfa keto glutarate
- cirrhosis
- mTORC1, mammalian target of rapamycin complex 1
- nutrition
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Benjamin J, Shasthry V, Kaal CR, Anand L, Bhardwaj A, Pandit V, Arora A, Rajesh S, Pamecha V, Jain V, Kumar G, Loria A, Puri P, Joshi YK, Sarin SK. Characterization of body composition and definition of sarcopenia in patients with alcoholic cirrhosis: A computed tomography based study. Liver Int 2017; 37:1668-1674. [PMID: 29065258 DOI: 10.1111/liv.13509] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 06/21/2017] [Indexed: 02/13/2023]
Abstract
BACKGROUND Alterations in body composition (BC) as loss of fat and muscle mass (sarcopenia) are associated with poor outcome in alcoholic cirrhosis (ALC). Prevalence of sarcopenia depends upon the method of assessment. Computed Tomography (CT) is a gold standard tool for assessing BC. AIM To characterize BC and define sarcopenia in ALC patients using CT. METHODS Single slice CT images at L3 vertebrae of healthy controls (HC) - organ transplant donors and ALC patients were analysed to give cross-sectional area of five skeletal muscles normalized for height -skeletal muscle index (SMI; cm2 /m2 ), area of subcutaneous (SAT;cm2 ) and visceral adipose tissue (VAT;cm2 ). Cut-offs for defining sarcopenia was established at 2SD below the mean of HC. HC were compared with Child A-compensated (C) and Child B+C-decompensated (DC) patients. RESULTS Cut-offs of SMI derived from HC (n = 275; M: 50%; age 32.2 ± 9.8 years; BMI 24.2 ± 3.2 Kg/m2 ) were 36.54 in males and 30.21 in females. Sarcopenia was found in 12.8% of ALC patients [n = 148; C (31.8%): DC (68.2%); M: 100%; age 46.6 ± 9.7 years; BMI 24.5 ± 4.4]. Compared to HC, compensated patients had higher adiposity and comparable muscularity; decompensated patients had significantly lower muscle and also fat mass compared to both HC and compensated patients. HC vs C vs DC: SAT (140 ± 82 vs 177.3 ± 11 vs 112 ± 8.2); VAT (96.5 ± 6.5 vs 154.9 ± 8.7 vs 87.5 ± 6.5) and SMI (52.1 ± 0.9 vs 49.6 ± 1.2 vs 46 ± 0.9). CONCLUSIONS Compensated ALC have increased adiposity and relatively preserved muscularity but decompensation leads to loss of both muscle and fat mass. Prevalence of sarcopenia, based on derived ethnic cut-offs was 12.8%.
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Affiliation(s)
- Jaya Benjamin
- Department of Clinical Nutrition, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Varsha Shasthry
- Department of Clinical Nutrition, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chetan Ramesh Kaal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Lovkesh Anand
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankit Bhardwaj
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vanshja Pandit
- Department of Clinical Nutrition, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankur Arora
- Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sasidharan Rajesh
- Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Viniyendra Pamecha
- Department of Liver Transplantation and Hepato Pancreatico Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikas Jain
- Department of Urology and Renal Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Anthony Loria
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, Richmond, VA, USA
| | - Puneet Puri
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, Richmond, VA, USA
| | - Yogendra Kumar Joshi
- Department of Clinical Nutrition, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Barone M, Viggiani MT, Avolio AW, Iannone A, Rendina M, Di Leo A. Obesity as predictor of postoperative outcomes in liver transplant candidates: Review of the literature and future perspectives. Dig Liver Dis 2017; 49:957-966. [PMID: 28801180 DOI: 10.1016/j.dld.2017.07.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 07/07/2017] [Accepted: 07/13/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current American and European guidelines consider a pre-transplant BMI ≥40kg/m2 as a relative contraindication for liver transplantation but this recommendation is graded as uncertain and requires further research. Moreover, conflicting results are reported on the predictive value of BMI 30-39.9kg/m2 on post-transplant complication and mortality risk. AIM This study analyzed the data of the literature on the effect of all three BMI classes of obesity on postoperative outcomes in liver transplantation. MATERIALS AND METHODS A PubMed and Cochrane Library search was conducted from inception to October 2015. RESULTS Analysis of the literature demonstrates that discrepancies among studies are mainly either due to limitations of BMI per se, the different BMI cut-offs used to select patients with obesity or reference group and the different outcomes considered. Moreover, the evaluation of visceral adipose tissue and the detrimental effect of muscle mass reduction in presence of obesity are never considered. CONCLUSIONS BMI assessment should be used as a preliminary method to evaluate obesity. Subsequently, the assessment of visceral adipose tissue and muscle mass should complete the preoperative evaluation of liver transplant candidates. This innovative approach could represent a new field of research in liver transplantation.
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Affiliation(s)
- Michele Barone
- Gastroenterology Unit, Dept. of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy.
| | - Maria Teresa Viggiani
- Gastroenterology Unit, Dept. of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Alfonso W Avolio
- Transplantation Service, Dept of Surgery, Catholic University, Rome, Italy
| | - Andrea Iannone
- Gastroenterology Unit, Dept. of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Maria Rendina
- Gastroenterology Unit, Dept. of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Alfredo Di Leo
- Gastroenterology Unit, Dept. of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
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Belarmino G, Gonzalez MC, Sala P, Torrinhas RS, Andraus W, D’Albuquerque LAC, Pereira RMR, Caparbo VF, Ferrioli E, Pfrimer K, Damiani L, Heymsfield SB, Waitzberg DL. Diagnosing Sarcopenia in Male Patients With Cirrhosis by Dual-Energy X-Ray Absorptiometry Estimates of Appendicular Skeletal Muscle Mass. JPEN J Parenter Enteral Nutr 2017; 42:24-36. [DOI: 10.1177/0148607117701400] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 02/21/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Giliane Belarmino
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Maria Cristina Gonzalez
- Postgraduate Program in Health and Behavior, Universidade Católica de Pelotas, Rio Grande do Sul, Brazil
- Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Priscila Sala
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Raquel Susana Torrinhas
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Wellington Andraus
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Rosa Maria R. Pereira
- Laboratory of Bone Metabolism, Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Valéria F. Caparbo
- Laboratory of Bone Metabolism, Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Ferrioli
- Department of Medical Clinic, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, São Paulo, Brazil
| | - Karina Pfrimer
- Department of Medical Clinic, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, São Paulo, Brazil
| | - Lucas Damiani
- Research Institute, Hospital do Coração de São Paulo, São Paulo, Brazil
| | | | - Dan L. Waitzberg
- Department of Gastroenterology (LIM 35), Surgical Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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25
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Ye Q, Yin W, Zhang L, Xiao H, Qi Y, Liu S, Qian B, Wang F, Han T. The value of grip test, lysophosphatidlycholines, glycerophosphocholine, ornithine, glucuronic acid decrement in assessment of nutritional and metabolic characteristics in hepatitis B cirrhosis. PLoS One 2017; 12:e0175165. [PMID: 28384211 PMCID: PMC5383249 DOI: 10.1371/journal.pone.0175165] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/21/2017] [Indexed: 02/06/2023] Open
Abstract
The liver is essential for the regulation of energy, protein and amino acids, as well as in other aspects of metabolism. To identify efficient indexes for evaluation of nutritional status and metabolic characteristics during different Child-Pugh stages of hepatitis B cirrhosis, 83 patients and 35 healthy individuals were enrolled in our study. We found that grip strength, triceps skinfold thickness (TSF), body fat and skeletal muscle of the patients were reduced compared to the control group (P<0.05). Ultra-high-performance liquid chromatography data combined with mass spectrometry (UPLC-MS) showed that levels of a variety of metabolites, including lysophosphatidylcholines (LysoPCs), glycerophosphocholine, ornithine and glucuronic acid were reduced in the serum of patients with hepatitis B cirrhosis (P<0.001). However, glycerophosphoserine and taurocholic acid levels were higher than in the control group (P<0.001). Moreover, grip strength was correlated with the Child-Pugh score (P<0.05). Serum albumin, total cholesterol, LDL, LysoPCs, glycerophosphocholine, ornithine, glucuronic acid, glycerophosphoserine and taurocholic acid were correlated with the Child-Pugh score (P<0.01). These findings suggested that grip strength and the above small molecular substances might be considered as sensitive and important indexes for evaluating nutritional status and metabolic characteristics of patients with hepatitis B cirrhosis, which may help assess prognosis and adjust nutritional treatment.
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Affiliation(s)
- Qing Ye
- The Third Central Clinical College of Tianjin Medical University, Tianjin, PR China
- Department of Gastroenterology and Hepatology, Tianjin Key Laboratory of Artificial Cells, Tianjin Institute of Hepatobiliary Disease, Tianjin Third Central Hospital, Tianjin, PR China
| | - Weili Yin
- The Third Central Clinical College of Tianjin Medical University, Tianjin, PR China
- Department of Gastroenterology and Hepatology, Tianjin Key Laboratory of Artificial Cells, Tianjin Institute of Hepatobiliary Disease, Tianjin Third Central Hospital, Tianjin, PR China
| | - Lei Zhang
- Clinical Laboratory of Tianjin Third Central Hospital, Tianjin, China
| | - Huijuan Xiao
- The Third Central Clinical College of Tianjin Medical University, Tianjin, PR China
- Department of Nutriology, Tianjin Third Central Hospital, Tianjin, China
| | - Yumei Qi
- Department of Nutriology, Tianjin Third Central Hospital, Tianjin, China
| | - Shuye Liu
- Clinical Laboratory of Tianjin Third Central Hospital, Tianjin, China
| | - Baoxin Qian
- The Third Central Clinical College of Tianjin Medical University, Tianjin, PR China
- Department of Gastroenterology and Hepatology, Tianjin Key Laboratory of Artificial Cells, Tianjin Institute of Hepatobiliary Disease, Tianjin Third Central Hospital, Tianjin, PR China
| | - Fengmei Wang
- The Third Central Clinical College of Tianjin Medical University, Tianjin, PR China
- Department of Gastroenterology and Hepatology, Tianjin Key Laboratory of Artificial Cells, Tianjin Institute of Hepatobiliary Disease, Tianjin Third Central Hospital, Tianjin, PR China
| | - Tao Han
- The Third Central Clinical College of Tianjin Medical University, Tianjin, PR China
- Department of Gastroenterology and Hepatology, Tianjin Key Laboratory of Artificial Cells, Tianjin Institute of Hepatobiliary Disease, Tianjin Third Central Hospital, Tianjin, PR China
- * E-mail:
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26
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Belarmino G, Gonzalez MC, Torrinhas RS, Sala P, Andraus W, D'Albuquerque LAC, Pereira RMR, Caparbo VF, Ravacci GR, Damiani L, Heymsfield SB, Waitzberg DL. Phase angle obtained by bioelectrical impedance analysis independently predicts mortality in patients with cirrhosis. World J Hepatol 2017; 9:401-408. [PMID: 28321276 PMCID: PMC5340995 DOI: 10.4254/wjh.v9.i7.401] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 12/22/2016] [Accepted: 01/11/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the prognostic value of the phase angle (PA) obtained from bioelectrical impedance analysis (BIA) for mortality prediction in patients with cirrhosis. METHODS In total, 134 male cirrhotic patients prospectively completed clinical evaluations and nutritional assessment by BIA to obtain PAs during a 36-mo follow-up period. Mortality risk was analyzed by applying the PA cutoff point recently proposed as a malnutrition marker (PA ≤ 4.9°) in Kaplan-Meier curves and multivariate Cox regression models. RESULTS The patients were divided into two groups according to the PA cutoff value (PA > 4.9°, n = 73; PA ≤ 4.9°, n = 61). Weight, height, and body mass index were similar in both groups, but patients with PAs > 4.9° were younger and had higher mid-arm muscle circumference, albumin, and handgrip-strength values and lower severe ascites and encephalopathy incidences, interleukin (IL)-6/IL-10 ratios and C-reactive protein levels than did patients with PAs ≤ 4.9° (P ≤ 0.05). Forty-eight (35.80%) patients died due to cirrhosis, with a median of 18 mo (interquartile range, 3.3-25.6 mo) follow-up until death. Thirty-one (64.60%) of these patients were from the PA ≤ 4.9° group. PA ≤ 4.9° significantly and independently affected the mortality model adjusted for Model for End-Stage Liver Disease score and age (hazard ratio = 2.05, 95%CI: 1.11-3.77, P = 0.021). In addition, Kaplan-Meier curves showed that patients with PAs ≤ 4.9° were significantly more likely to die. CONCLUSION In male patients with cirrhosis, the PA ≤ 4.9° cutoff was associated independently with mortality and identified patients with worse metabolic, nutritional, and disease progression profiles. The PA may be a useful and reliable bedside tool to evaluate prognosis in cirrhosis.
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Affiliation(s)
- Giliane Belarmino
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Maria Cristina Gonzalez
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Raquel S Torrinhas
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Priscila Sala
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Wellington Andraus
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Rosa Maria R Pereira
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Valéria F Caparbo
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Graziela R Ravacci
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Lucas Damiani
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Steven B Heymsfield
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
| | - Dan L Waitzberg
- Giliane Belarmino, Raquel S Torrinhas, Priscila Sala, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Graziela R Ravacci, Dan L Waitzberg, Department of Gastroenterology, Surgical Division, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo 05403-000, Brazil
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Hanai T, Shiraki M, Ohnishi S, Miyazaki T, Ideta T, Kochi T, Imai K, Suetsugu A, Takai K, Moriwaki H, Shimizu M. Rapid skeletal muscle wasting predicts worse survival in patients with liver cirrhosis. Hepatol Res 2016; 46:743-51. [PMID: 26579878 DOI: 10.1111/hepr.12616] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/23/2015] [Accepted: 10/30/2015] [Indexed: 02/08/2023]
Abstract
AIM Sarcopenia impairs the outcome of patients with liver cirrhosis independently of liver function reserves. The aim of this study was to investigate whether the rate of skeletal muscle wasting predicts mortality in cirrhotic patients. METHODS This retrospective study evaluated 149 cirrhotic patients who visited our hospital between March 2004 and September 2012. The skeletal muscle cross-sectional area at the level of the third lumbar vertebra was measured by computed tomography, from which the skeletal muscle index was obtained for diagnosis of sarcopenia. The relative change in skeletal muscle area per year (ΔSMA/y) was calculated in each patient. Cox proportional hazards regression analysis was performed to evaluate risk factors for mortality. RESULTS Of the 149 cirrhotic patients, 94 (63%) were diagnosed with sarcopenia. The median of ΔSMA/y in all patients was -2.2%. For patients in Child-Pugh class A, B and C, ΔSMA/y was -1.3%, -3.5% and -6.1%, respectively. During a median follow-up period of 39 months (range, 1-110), 45 patients (30%) died. The optimal cut-off value of ΔSMA/y for predicting mortality was -3.1%; the survival rate in patients with ΔSMA/y of -3.1% or less was significantly lower than in patients with ΔSMA/y of more than -3.1% (P < 0.0001). The multivariate Cox proportional hazards model found ΔSMA/y of -3.1% or less to be significantly associated with mortality in cirrhotic patients (hazard ratio = 2.73, 95% confidence interval = 1.43-5.44, P < 0.01). CONCLUSION ΔSMA/y is useful for predicting mortality in patients with liver cirrhosis. Management of skeletal muscle may contribute toward improving the outcome of cirrhotic patients.
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Affiliation(s)
- Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Makoto Shiraki
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Sachiyo Ohnishi
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Tsuneyuki Miyazaki
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takayasu Ideta
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takahiro Kochi
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kenji Imai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Atsushi Suetsugu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Koji Takai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.,Division for Regional Cancer Control, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hisataka Moriwaki
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
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Prieto-Frías C, Conchillo M, Payeras M, Iñarrairaegui M, Davola D, Frühbeck G, Salvador J, Rodríguez M, Richter JÁ, Mugueta C, Gil MJ, Herrero I, Prieto J, Sangro B, Quiroga J. Factors related to increased resting energy expenditure in men with liver cirrhosis. Eur J Gastroenterol Hepatol 2016; 28:139-45. [PMID: 26560751 DOI: 10.1097/meg.0000000000000516] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Hypermetabolism in cirrhosis is associated with a high risk of complications and mortality. However, studies about underlying mechanisms are usually focussed on isolated potential determinants and specific etiologies, with contradictory results. We aimed at investigating differences in nutrition, metabolic hormones, and hepatic function between hypermetabolic and nonhypermetabolic men with cirrhosis of the liver. PATIENTS AND METHODS We prospectively enrolled 48 male cirrhotic inpatients. We evaluated their resting energy expenditure (REE) and substrate utilization by indirect calorimetry, body composition by dual-energy X-ray absorptiometry, liver function, and levels of major hormones involved in energy metabolism by serum sample tests. Patients with ascites, specific metabolic disturbances, and hepatocellular carcinoma were excluded. RESULTS REE and REE adjusted per fat-free mass (FFM) were significantly increased in cirrhotic patients. Overall, 58.3% of cirrhotic patients were classified as hypermetabolic. Groups did not differ significantly in age, etiology of cirrhosis, liver function, presence of ascites, use of diuretics, β-blockers, or presence of transjugular intrahepatic portosystemic shunts. Hypermetabolic cirrhotic patients had lower weight, BMI (P<0.05), nonprotein respiratory quotient (P<0.01), leptin (P<0.05), and leptin adjusted per fat mass (FM) (P<0.05), but higher FFM% (P<0.05) and insulin resistance [homeostatic model assessment-insulin resistance (HOMA-IR)] (P<0.05). Only HOMA-IR, leptin/FM, and FFM% were independently related to the presence of hypermetabolism. CONCLUSION Hypermetabolic cirrhotic men are characterized by lower weight, higher FFM%, insulin resistance, and lower leptin/FM when compared with nonhypermetabolic men. HOMA-IR, FFM%, and leptin/FM were independently associated with hypermetabolism, and may serve as easily detectable markers of this condition in daily clinical practice.
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Affiliation(s)
- César Prieto-Frías
- aDepartment of Gastroenterology bLiver Unit, Department of Medicine cDepartment of Endocrinology dDepartment of Nuclear Medicine eDepartment of Laboratory Medicine, Clínica Universidad de Navarra fInstitute for Biomedical Research in Navarra (IDISNA), Pamplona gBiomedical Research Network in Liver and Digestive Diseases (CIBEREHD), Madrid, Spain
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29
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Nguyen T. Comparison of current practice and best practice guidelines for the nutritional management of patients with liver cirrhosis: An Australian survey of dietitians in clinical practice. Nutr Diet 2015. [DOI: 10.1111/1747-0080.12197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Trang Nguyen
- Department of Dietetics; Sydney South West Area of Health; Liverpool Hospital; Sydney New South Wales Australia
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30
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Zhou YJ, Yu ZJ. Nutritional assessment and treatment in patients with liver cirrhosis. Shijie Huaren Xiaohua Zazhi 2014; 22:4750-4756. [DOI: 10.11569/wcjd.v22.i31.4750] [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] [Indexed: 02/06/2023] Open
Abstract
Liver cirrhosis is a worldwide disease with high morbidity. Patients with liver cirrhosis are often complicated with malnutrition, and nutritional status has close relationship with prognosis. Currently, there has been no unified standard to assess the nutrition status of patients with liver cirrhosis; several tools should be combined in order to generate more accurate evaluation. A reasonable nutritional intervention should be given to improve the prognosis of patients with cirrhosis. This review focuses on essential aspects in the nutritional assessment and support in cirrhotic patients to provide a basis for correctly assessing the patient's nutritional status and providing adequate nutritional treatment.
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31
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The short-term effect of liver transplantation on the nutritional status of Egyptian patients with end-stage liver disease. EGYPTIAN LIVER JOURNAL 2014. [DOI: 10.1097/01.elx.0000454685.83533.8a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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32
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Giusto M, Lattanzi B, Di Gregorio V, Giannelli V, Lucidi C, Merli M. Changes in nutritional status after liver transplantation. World J Gastroenterol 2014; 20:10682-10690. [PMID: 25152572 PMCID: PMC4138449 DOI: 10.3748/wjg.v20.i31.10682] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
Chronic liver disease has an important effect on nutritional status, and malnourishment is almost universally present in patients with end-stage liver disease who undergo liver transplantation. During recent decades, a trend has been reported that shows an increase in number of patients with end-stage liver disease and obesity in developed countries. The importance of carefully assessing the nutritional status during the work-up of patients who are candidates for liver replacement is widely recognised. Cirrhotic patients with depleted lean body mass (sarcopenia) and fat deposits have an increased surgical risk; malnutrition may further impact morbidity, mortality and costs in the post-transplantation setting. After transplantation and liver function is restored, many metabolic alterations are corrected, dietary intake is progressively normalised, and lifestyle changes may improve physical activity. Few studies have examined the modifications in body composition that occur in liver recipients. During the first 12 mo, the fat mass progressively increases in those patients who had previously depleted body mass, and the muscle mass recovery is subtle and non-significant by the end of the first year. In some patients, unregulated weight gain may lead to obesity and may promote metabolic disorders in the long term. Careful monitoring of nutritional changes will help identify the patients who are at risk for malnutrition or over-weight after liver transplantation. Physical and nutritional interventions must be investigated to evaluate their potential beneficial effect on body composition and muscle function after liver transplantation.
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Mouzaki M, Ng V, Kamath BM, Selzner N, Pencharz P, Ling SC. Enteral Energy and Macronutrients in End-Stage Liver Disease. JPEN J Parenter Enteral Nutr 2014; 38:673-681. [DOI: 10.1177/0148607114522488] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto
- Department of Paediatrics, University of Toronto, Toronto
| | - Vicky Ng
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto
- Department of Paediatrics, University of Toronto, Toronto
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto
- Department of Paediatrics, University of Toronto, Toronto
| | - Nazia Selzner
- Division of Medicine, University Health Network, Toronto
| | - Paul Pencharz
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto
- Department of Paediatrics, University of Toronto, Toronto
| | - Simon C. Ling
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto
- Department of Paediatrics, University of Toronto, Toronto
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Anastácio LR, Diniz KG, Ribeiro HS, Ferreira LG, Lima AS, Correia MITD, Vilela EG. Prospective evaluation of metabolic syndrome and its components among long-term liver recipients. Liver Int 2014; 34:1094-101. [PMID: 24517561 DOI: 10.1111/liv.12495] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 02/04/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Survival after liver transplantation (LTx) has increased. Metabolic syndrome (MS) is widely reported in patients in the early years after LTx; few studies have researched this condition in relatively long-term liver recipients. To describe, prospectively, the prevalence of MS, its components and its associated factors in relatively long-term liver recipients. METHODS A total of 117 patients were evaluated in 2008 (median of 3 years after LTx, range 0-13 years) and in 2012 (median of 7 years after LTx, range 3-17 years) for the presence of MS [using modified NCEP Adult Treatment Panel III and International Diabetes Federation (IDF) criteria]; its components; and its associated factors, including demographic, socioeconomic, lifestyle, clinical, body composition (measured using bioelectric impedance) and dietetic factors. RESULTS MS increased over the years (IDF, 43.1-53.3%, P=0.12; and NCEP, 34.3-44.8%, P=0.03). Blood glucose increased over the years (98.8±24.7 to 109.2±33.3 mg/dl, P<0.01), which resulted in an increased prevalence of glucose intolerance (34.2-48.6%, P<0.01). Waist circumference (93.3±14.3 to 99.4±14.9 cm, P<0.01) and body fat (30.3±8.9 to 31.8±10.3%, P=0.03) also increased. The MS associated factors (P<0.05) were age [Odds ratio (OR) 1.05, confidence interval (CI) 1.02-1.11], family history of diabetes (OR 3.38, CI 1.19-9.61), body mass index (BMI) prior to liver disease (OR 1.39, CI 1.19-1.63) and body fat (OR 1.09, CI 1.03-1.14). The MS components were associated (P<0.05) with greater age, family history of diabetes, current and previous BMI, body fat, current corticosteroid use, lack of exercise and greater carbohydrate and fat intakes. CONCLUSION MS prevalence increased over the years after LTx because of the increases in waist circumference and blood glucose. MS and its components are associated with modifiable factors, such as greater BMI, body fat and carbohydrate and fat intake.
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Affiliation(s)
- Lucilene R Anastácio
- Adult Health Post Graduation Program, Medical School, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Montano-Loza AJ. Clinical relevance of sarcopenia in patients with cirrhosis. World J Gastroenterol 2014; 20:8061-71. [PMID: 25009378 PMCID: PMC4081677 DOI: 10.3748/wjg.v20.i25.8061] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 01/13/2014] [Accepted: 03/12/2014] [Indexed: 02/07/2023] Open
Abstract
The most commonly recognized complications in cirrhotic patients include ascites, hepatic encephalopathy, variceal bleeding, susceptibility for infections, kidney dysfunction, and hepatocellular carcinoma; however, severe muscle wasting or sarcopenia are the most common and frequently unseen complications which negatively impact survival, quality of life, and response to stressor, such as infections and surgeries. At present, D'Amico stage classification, Child-Pugh, and MELD scores constitute the best tools to predict mortality in patients with cirrhosis; however, one of their main limitations is the lack of assessing the nutritional and functional status. Currently, numerous methods are available to evaluate the nutrition status of the cirrhotic patient; nevertheless, most of these techniques have limitations primarily because lack of objectivity, reproducibility, and prognosis discrimination. In this regard, an objective and reproducible technique, such as muscle mass quantification with cross-sectional imaging studies (computed tomography scan or magnetic resonance imaging) constitute an attractive index of nutritional status in cirrhosis. Sarcopenia is part of the frailty complex present in cirrhotic patients, resulting from cumulative declines across multiple physiologic systems and characterized by impaired functional capacity, decreased reserve, resistance to stressors, and predisposition to poor outcomes. In this review, we discuss the current accepted and new methods to evaluate prognosis in cirrhosis. Also, we analyze the current knowledge regarding incidence and clinical impact of malnutrition and sarcopenia in patients with cirrhosis and their impact after liver transplantation. Finally, we discuss existing and potential novel therapeutic approaches for malnutrition in cirrhosis, emphasizing the recognition of sarcopenia in an effort to reduced morbidity related and improved survival in cirrhosis.
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Kwarta E, Nagle S, Welstead L. Update on Malnutrition in Liver Cirrhosis: Assessment and Treatment. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s11901-014-0230-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Wu SN, Qi YM, Chen YJ, Xiao HJ, Hao CM, Wang X. Intracellular and extracellular water distribution in patients with liver cirrhosis. Shijie Huaren Xiaohua Zazhi 2013; 21:4170-4174. [DOI: 10.11569/wcjd.v21.i36.4170] [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] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate intracellular water (ICW) and extracellular water (ECW) distribution in patients with cirrhosis.
METHODS: One hundred and four cirrhotic patients were divided into three groups based on Child-Pugh class (A, B, C), and 24 healthy volunteers were used as controls (n). Total body water (TBW), ICW and ECW were measured by multi-frequency bioelectrical impedance. ICW% was calculated as ICW/TBW × 100%, and ECW% as ECW/TBW × 100%.
RESULTS: Intracellular and extracellular fluid distribution changed in patients with cirrhosis. With the increase in Child-Pugh class, ECW and ECW% increased and ICW% and ICW/TBW decreased (ECW: 13.011 ± 2.517 L, 14.463 ± 2.720 L, 14.587 ± 2.976 L vs 13.300 ± 2.073 L; ECW%: 38.93% ± 1.10%, 39.87% ± 1.00%, 40.52% ± 1.32% vs 38.52% ± 0.95%; ICW%: 61.07% ± 1.10%, 60.03% ± 1.00%, 59.48% ± 1.32% vs 61.48% ± 0.95%; ICW/ECW: 1.571 ± 0.072, 1.510 ± 0.063, 1.470 ± 0.789, 1.598 ± 0.065).
CONCLUSION: Intracellular and extracellular fluid distribution has changed at the beginning of the disease in cirrhotic patients, which manifests as increased ECW and ECW% and decreased ICW% and ICW/TBW.
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Amodio P, Bemeur C, Butterworth R, Cordoba J, Kato A, Montagnese S, Uribe M, Vilstrup H, Morgan MY. The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. Hepatology 2013; 58:325-36. [PMID: 23471642 DOI: 10.1002/hep.26370] [Citation(s) in RCA: 263] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 02/25/2013] [Indexed: 12/12/2022]
Abstract
UNLABELLED Nitrogen metabolism plays a major role in the development of hepatic encephalopathy (HE) in patients with cirrhosis. Modulation of this relationship is key to the management of HE, but is not the only nutritional issue that needs to be addressed. The assessment of nutritional status in patients with cirrhosis is problematic. In addition, there are significant sex-related differences in body composition and in the characteristics of tissue loss, which limit the usefulness of techniques based on measures of muscle mass and function in women. Techniques that combine subjective and objective variables provide reasonably accurate information and are recommended. Energy and nitrogen requirements in patients with HE are unlikely to differ substantially from those recommended in patients with cirrhosis per se viz. 35-45 kcal/g and 1.2-1.5g/kg protein daily. Small meals evenly distributed throughout the day and a late-night snack of complex carbohydrates will help minimize protein utilization. Compliance is, however, likely to be a problem. Diets rich in vegetables and dairy protein may be beneficial and are therefore recommended, but tolerance varies considerably in relation to the nature of the staple diet. Branched chain amino acid supplements may be of value in the occasional patient intolerant of dietary protein. Increasing dietary fiber may be of value, but the utility of probiotics is, as yet, unclear. Short-term multivitamin supplementation should be considered in patients admitted with decompensated cirrhosis. Hyponatremia may worsen HE; it should be prevented as far as possible and should always be corrected slowly. CONCLUSION Effective management of these patients requires an integrated multidimensional approach. However, further research is needed to fill the gaps in the current evidence base to optimize the nutritional management of patients with cirrhosis and HE.
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Affiliation(s)
- Piero Amodio
- Department of Medicine University Hospital of Padua Padova Italy.
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Johnson TM, Overgard EB, Cohen AE, DiBaise JK. Nutrition Assessment and Management in Advanced Liver Disease. Nutr Clin Pract 2013; 28:15-29. [DOI: 10.1177/0884533612469027] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | | | | | - John K. DiBaise
- Division of Gastroenterology, Mayo Clinic in Arizona, Phoenix, Arizona
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Bonefeld K, Hobolth L, Juul A, Møller S. The insulin like growth factor system in cirrhosis. Relation to changes in body composition following adrenoreceptor blockade. Growth Horm IGF Res 2012; 22:212-218. [PMID: 23031335 DOI: 10.1016/j.ghir.2012.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 08/30/2012] [Accepted: 09/03/2012] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Circulating levels of IGF-I and IGFBP-3 are low in cirrhosis and are related to liver dysfunction. Metabolic disturbances include malnutrition with altered body composition and osteopenia. Since the effects of IGF-I may be associated to changes in body composition and bone mineral content (BMC) in cirrhotic patients, we investigated the relations between changes in the IGF-system and body composition and the effects of long-term alpha- and beta-blockade. DESIGN The study was designed as a combined cross-sectional and prospective randomised controlled study of 62 patients with cirrhosis. Twenty-three of these patients were randomised to treatment with beta- or combined alpha/beta-blocker for 3 months. Haemodynamics, body composition, and systemic and hepatic IGF-I and IGFBP-3 levels were determined in all patients. In the subgroup changes in body composition and IGF-I/IGFBP-3 levels after 3 months of beta- or combined alpha/beta-blockade were additionally examined. RESULTS Both the hepatic and the systemic IGF systems were suppressed and correlated with liver dysfunction and anthropometrics (p<0.05-0.001). Multivariate analyses revealed that changes in the IGF-system were determined by metabolic liver dysfunction as well as anthropometrics. In the follow-up study, hepatic venous IGF-I (p=0.05) and IGFBP-3 (p=0.02) increased after 3 months only in the group who received beta-blocker. In both groups, fat body mass increased significantly after 3 months (p=0.05-0.001). CONCLUSIONS In cirrhosis, the IGF-system is associated with both anthropometrics and synthetic capacity of the liver. Changes in IGF-I relate to changes in anthropometrics and there seems to be a differential effect depending on the type of adrenoreceptor blockade. Future longitudinal studies are needed to unravel these mechanisms in cirrhosis.
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Affiliation(s)
- Karen Bonefeld
- Centre of Functional and Diagnostic Imaging and Research, Section of Clinical Physiology and Nuclear Medicine, Hvidovre Hospital, Denmark
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Watt KD. Reducing the load: the evolution and management of obesity and nonalcoholic steatohepatitis before liver transplantation. Liver Transpl 2012; 18 Suppl 2:S52-8. [PMID: 22821716 DOI: 10.1002/lt.23515] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
1. Obesity is common in patients with end-stage liver disease of any cause. 2. Obesity is associated with comorbidities that can affect liver transplant candidacy, such as metabolic syndrome (diabetes, hyperlipidemia, and hypertension), cardiovascular disease, pulmonary disorders (related to obstructive sleep apnea), renal dysfunction, and malignancies. 3. Nonalcoholic steatohepatitis is the only indication for transplantation that is increasing in frequency, and it may soon become the leading indication. 4. There is no set body mass index above which liver transplantation is contraindicated. Transplant candidacy and outcomes depend on the cumulative comorbidities of the individual patient. 5. Weight loss is an important component of metabolic syndrome management and is recommended before liver transplantation. 6. Bariatric surgery may be considered in carefully selected patients with well-compensated cirrhosis but is not recommended in patients with decompensated cirrhosis.
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Affiliation(s)
- Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA.
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Periyalwar P, Dasarathy S. Malnutrition in cirrhosis: contribution and consequences of sarcopenia on metabolic and clinical responses. Clin Liver Dis 2012; 16:95-131. [PMID: 22321468 PMCID: PMC4383161 DOI: 10.1016/j.cld.2011.12.009] [Citation(s) in RCA: 175] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Malnutrition is the most common, reversible complication of cirrhosis that adversely affects survival, response to other complications, and quality of life. Sarcopenia, or loss of skeletal muscle mass, and loss of adipose tissue and altered substrate use as a source of energy are the 2 major components of malnutrition in cirrhosis. Current therapies include high protein supplementation especially as a late evening snack. Exercise protocols have the potential of aggravating hyperammonemia and portal hypertension. Recent advances in understanding the molecular regulation of muscle mass has helped identify potential novel therapeutic targets including myostatin antagonists, and mTOR resistance.
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Affiliation(s)
- Pranav Periyalwar
- Department of Gastroenterology, Metrohealth Medical Center, 2500 Metrohealth Drive, Cleveland, OH 44109, USA
- Department of Gastroenterology and Hepatology, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, NE4-208, Cleveland, OH 44195, USA
| | - Srinivasan Dasarathy
- Department of Gastroenterology and Hepatology, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, NE4-208, Cleveland, OH 44195, USA
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, NE4-208, Cleveland, OH 44195, USA
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Merli M, Giusto M, Giannelli V, Lucidi C, Riggio O. Nutritional status and liver transplantation. J Clin Exp Hepatol 2011; 1:190-8. [PMID: 25755385 PMCID: PMC3940406 DOI: 10.1016/s0973-6883(11)60237-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 11/22/2011] [Indexed: 12/12/2022] Open
Abstract
Chronic liver disease has a profound effect on nutritional status and undernourishment is almost universally present in patients with end-stage liver disease undergoing liver transplantation. In the last decades, due to epidemiological changes, a trend showing an increase in patients with end-stage liver disease and associated obesity has also been reported in developed countries. Nutrition abnormalities may influence the outcome after transplantation therefore, the importance to carefully assess the nutritional status in the work-up of patients candidates for liver transplantation is widely accepted. More attention has been given to malnourished patients as they represent the greater number. The subjective global nutritional assessment and anthropometric measurements are recognized in current guidelines to be adequate in identifying those patients at risk of malnutrition. Cirrhotic patients with a depletion in lean body mass and fat deposits have an increased surgical risk and malnutrition may impact on morbidity, mortality and costs in the post-transplantation setting. For this reason an adequate calorie and protein intake should always be ensured to malnourished cirrhotic patient either through the diet, or using oral nutritional supplements or by enteral or parenteral nutrition although studies supporting the efficacy of nutritional supplementation in improving the clinical outcomes after transplantation are still scarce. When liver function is restored, an amelioration in the nutritional status is expected. After liver transplantation in fact dietary intake rapidly normalizes and fat mass is progressively regained while the recovery of muscle mass can be slower. In some patients unregulated weight gain may lead to over-nutrition and may favor metabolic disorders (hypertension, hyperglycemia, hyperlipidemia). This condition, defined as 'metabolic syndrome', may play a negative role on the overall survival of liver transplant patients. In this report we review data on nutrition and liver transplantation.
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Affiliation(s)
- Manuela Merli
- Address for correspondence: Manuela Merli, II Gastroenterologia, Dipartimento di Medicina Clinica, Viale dell'Università 37, 00185 Roma, Italy
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Hara N, Iwasa M, Iwata K, Miyachi H, Tanaka H, Takeo M, Fujita N, Kobayashi Y, Takei Y. Value of the extracellular water ratio for assessment of cirrhotic patients with and without ascites. Hepatol Res 2009; 39:1072-9. [PMID: 19619257 DOI: 10.1111/j.1872-034x.2009.00546.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIMS Ascites, which often complicates liver cirrhosis, is reported to be a factor that worsens the outcome. The aims of this study were to quantify body water compartment changes in cirrhotic patients, with and without ascites, and to elucidate the value of body water analysis for predicting the development of ascites. METHODS A total of 109 cirrhotic patients, with and without ascites, and 65 controls were studied. Intra- and extracellular water (ECW) in the whole body and in the arm, leg and trunk were measured using the recently developed 8-electrodes multiple-frequency bioelectrical impedance analyzer. Furthermore, patients without ascites were followed to an episode of ascites or death. RESULTS Patients with liver cirrhosis had significantly higher ECW ratios than controls. ECW ratios were increased in cirrhotic patients with moderate and severe disease. The ECW ratio of the trunk showed highly significant changes in cirrhotic patients with ascites. The ECW ratio correlated with age, serum albumin, and prothrombin time. A relative expansion of ECW and low albumin were predictive of further episodes of ascites (log-rank 6.94, P < 0.01). In multivariate analysis, the ECW ratio was independently associated with the development of ascites. CONCLUSION Liver cirrhosis was characterized by a redistribution of body water. The ECW ratio is a reliable tool for quantification of redistribution of body water and can predict the development of ascites.
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Affiliation(s)
- Nagisa Hara
- Department of Gastroenterology and Hepatology, Division of Clinical Medicine and Biomedical Sciences, Institute of Medical Science, Mie University Graduate School of Medicine, and
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Affiliation(s)
- Srinivasan Dasarathy
- Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Schneider ACR, Pinto RB, Silveira TRD. [Nutritional risk and malnutrition determination by anthropometry in cirrhotic children and adolescents]. ARQUIVOS DE GASTROENTEROLOGIA 2008; 44:345-9. [PMID: 18317655 DOI: 10.1590/s0004-28032007000400012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND The malnutrition is a frequent finding in adults with cirrhosis, but the prevalence of nutritional risk and malnutrition is little known in pediatric patients. AIM To evaluate through anthropometry the presence of nutritional risk and malnutrition in cirrhotic pediatric patients regularly attended at the Pediatric Gastroenterology Service of "Hospital de Clínicas" of Porto Alegre, RS, Brazil. METHODS Cross-sectional study with 42 cirrhotic children and adolescents aged between 3 months and 18 years. The nutritional evaluation was made by the determination of the weight/age, height/age, body mass index and triceps skinfold thickness and arm muscle circumference measurements. Patients considered in nutritional risk were < or = -1,28 Z score which corresponds to < or = 10th percentile, and those under -2,0 Z and < or = 3th percentile were in malnutrition status. According to Child-Pugh criteria, 22 patients were classified as A (mild severity), 15 (moderate) B and 5 C (intense). RESULTS The mean weight/age, height/age and body mass index Z scores were, respectively, - 0,38 +/- 1,4 SD, - 0,83 +/- 1,16 SD and 0,17 +/- 1,3 SD. Patients in nutritional risk were 3/42 (weight/age), 8/42 (height/age), 12/37 (triceps skinfold thickness), 9/37 (arm muscle circumference), 2/38 (body mass index); in malnutrition status were 6/42 (weight/age), 7/42 (height/age), 4/37 (triceps skinfold thickness) and 4/37 (arm muscle circumference) and 3/38 (body mass index). CONCLUSION The prevalence of nutritional risk was 32.4% and chronic malnutrition was 16.7%. The index which better reflected the nutritional risk in these patients was triceps skinfold thickness. Chronic malnutrition status occurrence was greater in the height/age index.
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Affiliation(s)
- Ana Cláudia Reis Schneider
- Setor de Gastroenterologia Pediátrica, Departamento de Pediatria do Hospital de Clínicas de Porto Alegre, RS, Brazil
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Carvalho L, Parise ER. Evaluation of nutritional status of nonhospitalized patients with liver cirrhosis. ARQUIVOS DE GASTROENTEROLOGIA 2007; 43:269-74. [PMID: 17406753 DOI: 10.1590/s0004-28032006000400005] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2005] [Accepted: 08/29/2006] [Indexed: 02/09/2023]
Abstract
BACKGROUND [corrected] Protein-calorie malnutrition is a frequent finding in patients with chronic liver disease, but investigations of nutritional status have been rarely performed in individuals seen at outpatient clinics AIM To evaluate the nutritional status of patients with alcoholic and nonalcoholic cirrhosis, attended for the first time at a reference outpatient clinic for liver diseases. PATIENTS AND METHODS A total of 300 consecutive patients attended at the outpatient clinics of a reference center for liver diseases were investigated. Anthropometric evaluation was performed by the usual parameters: triceps skinfold, arm circumference and arm muscle circumference. Biochemical parameters included creatinine/height index, serum albumin and lymphocytes count. The nutritional diagnosis was based on the PCM score proposed by Mendenhall et al. Food intake was retrospectively evaluated using 24-hour dietary recall data. RESULTS About 71% of the patients studied were chronic alcohol abusers, whereas in 29% cirrhosis was of nonalcoholic etiology. Independently of the disease etiology 75.3% of the patients showed some degree of protein-calorie malnutrition, which was moderate or severe in 38.3% of them. More advanced protein-calorie malnutrition degrees were associated with lower energy and protein intake. The prevalence of moderate or severe protein-calorie malnutrition was higher in patients classified as Child-Pugh C than in patients classified as Child-Pugh A (21% x 58%, respectively). Regarding sexual differences, fat reserves, evaluated by triceps skinfold, were more depleted in females than in males (48.6% x 26.6%) regardless of the etiology of the cirrhosis, whereas muscle reserves (arm muscle circumference) were more depleted in males (43.4% x 13.4%) regardless of the etiology of cirrhosis. In contrast, cirrhosis of alcoholic etiology was determinant in reducing arm muscle circumference in females (20% x 9.1%) CONCLUSIONS These data highlight the high prevalence of protein-calorie malnutrition occurring early in the natural history of the disease and accompanying functional hepatic deterioration. In addition, attention should be paid to the different gender patterns of response to protein-calorie malnutrition in these patients.
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Affiliation(s)
- Luciana Carvalho
- Gastroenterology Section, Federal São Paulo University, São Paulo, SP, Brazil
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Morgan MY, Madden AM, Jennings G, Elia M, Fuller NJ. Two-component models are of limited value for the assessment of body composition in patients with cirrhosis. Am J Clin Nutr 2006; 84:1151-62. [PMID: 17093169 DOI: 10.1093/ajcn/84.5.1151] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Most techniques for measuring body composition are based on 2-component models (2-CMs) and depend on assumptions relating to the constancy of the density (D(FFM)) and hydration fraction (HF(FFM)) of fat-free mass (FFM). OBJECTIVES The objectives were to determine whether these assumptions are systematically violated in patients with cirrhosis and to assess the validity of the estimates of body composition obtained in these patients by using 2-CM techniques. DESIGN Body composition was assessed by using a 4-component model (4-CM), which was based on data obtained from densitometry, deuterium dilution, and dual-energy X-ray absorptiometry, in 20 patients with cirrhosis who had no evidence of fluid retention and in 20 pair-matched healthy control subjects. The results were compared with those obtained by using "reference" and "bedside" 2-CM techniques. RESULTS The mean (+/-SD) D(FFM) was significantly lower in the patients with cirrhosis (1.091 +/- 0.008 compared with 1.100 +/- 0.006 kg/L; P < 0.001); no significant difference in HF(FFM) was observed between the patients and control subjects (74.5 +/- 2.6 compared with 73.5 +/- 2.1), although there was greater variability in the patients. Significant differences were observed in the body-composition variables obtained by using the "reference" 2-CM techniques compared with the 4-CM-the 95% limits of agreement in the patients with cirrhosis exceeded 5% body fat and 3 kg FFM; the corresponding values for the "bedside" 2-CM techniques were 11% body fat and 7.5 kg FFM. CONCLUSIONS Assumptions relating to the constancy of the D(FFM) and HF(FFM) are violated in patients with cirrhosis. Thus, standard 2-CM techniques provide inaccurate body composition estimates in this patient population.
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Affiliation(s)
- Marsha Y Morgan
- The UCL Institute of Hepatology, Hampstead Campus, Royal Free and University College Medical School, London, United Kingdom.
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Abstract
Liver disease secondary to alcohol ranges from alcoholic fatty liver disease to acute hepatitis to cirrhotic liver disease. It is imperative that alcohol be discontinued to allow for any potential improvement in liver function, with most benefit being seen in the early stages of the disease. Alcoholic liver disease has a profound effect on nutrient intake, nutrition status, and metabolism, contributing to a high prevalence of malnutrition in this population. Early intervention with nutrition therapy may improve response to treatment, alleviate symptoms, and improve quality and quantity of life. In this review, nutrition assessment parameters and medical nutrition therapy goals for alcoholic liver disease are discussed.
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Affiliation(s)
- Sara R DiCecco
- William J. von Liebig Transplant Center, Mayo Clinic Rochester, 201 W. Center Street, Rochester, MN 55902, USA.
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