1
|
Yuan C, Li W, Liu J, Li J. Frailty and transplant-free survival of patients with liver cirrhosis: A meta-analysis. PLoS One 2024; 19:e0302836. [PMID: 38722913 PMCID: PMC11081249 DOI: 10.1371/journal.pone.0302836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/12/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Frailty is a common condition among patients with liver cirrhosis. Nonetheless, its role in predicting liver transplant-free survival (TFS) remains unclear. AIM This systematic review and meta-analysis were conducted to elucidate the relationship between frailty and TFS in patients with cirrhosis. METHODS Cohort studies addressing the objective of this meta-analysis were extracted from PubMed, Embase, and Web of Science databases. Between-study heterogeneity was assessed with the Cochrane Q test, and the I^2 statistic was estimated. Random-effect models, considering potential heterogeneity, were employed to combine the results. RESULTS The meta-analysis encompassed 17 cohort studies involving 6273 patients with cirrhosis, of whom 1983 (31.6%) were classified as frail at baseline. The follow-up periods in the included studies ranged from 3 to 29 months, with an average duration of 11.5 months. The analysis revealed that frailty was significantly associated with a poor TFS (risk ratio [RR]: 2.07, 95% confidence interval: 1.72 to 2.50, p<0.001; I2 = 51%). Sensitivity analyses that sequentially omitted one dataset consistently supported these findings (RR: 1.95 to 2.17, p<0.05 in all cases). Subgroup analyses based on variables such as study design, mean age of patients, baseline Model for End-Stage Liver Disease score, tool used for frailty evaluation, follow-up duration, and study quality score also yielded congruent results. CONCLUSIONS The evidence suggests that frailty may be an independent risk factor for poor TFS in patients with liver cirrhosis, thus emphasizing the importance of early identification and management of frailty in this population.
Collapse
Affiliation(s)
- Chunhui Yuan
- Department of Gastroenterology, Changsha Fourth Hospital, Changsha, Hunan Province, China
| | - Weihua Li
- Department of Gastroenterology, Changsha Fourth Hospital, Changsha, Hunan Province, China
| | - Jie Liu
- Department of Gastroenterology, Changsha Fourth Hospital, Changsha, Hunan Province, China
| | - Jianguo Li
- Department of Gastroenterology, Changsha Fourth Hospital, Changsha, Hunan Province, China
| |
Collapse
|
2
|
Román E, Kaür N, Sánchez E, Poca M, Padrós J, Nadal MJ, Cuyàs B, Alvarado E, Vidal S, Ortiz MÀ, Hernández E, Santesmases R, Urgell E, Juanes E, Ferrero-Gregori A, Escorsell À, Guarner C, Soriano G. Home exercise, branched-chain amino acids, and probiotics improve frailty in cirrhosis: A randomized clinical trial. Hepatol Commun 2024; 8:e0443. [PMID: 38701490 PMCID: PMC11073778 DOI: 10.1097/hc9.0000000000000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/04/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Frailty is a predictive factor of hospitalization, falls, and mortality in patients with cirrhosis, regardless of the degree of liver failure. The aim was to analyze whether a multifactorial intervention consisting of home-based exercise, branched-chain amino acids, and a multistrain probiotic can improve frailty in these patients. METHODS Outpatients with cirrhosis were classified according to the Liver Frailty Index (LFI). Prefrail and frail patients were randomized into 2 groups. The intervention group was assigned to a multifactorial intervention consisting of exercise at home, branched-chain amino acid supplements, and a multistrain probiotic for 12 months. The control group received standard care. All patients were prospectively followed up every 3 months for 1 year to determine LFI, incidence of falls, emergency room visits, hospitalizations, and mortality. RESULTS Thirty-two patients were included: 17 patients were assigned to the intervention group and 15 to the control group. In the intervention group, the baseline LFI decreased at 3, 6, 9, and 12 months (p = 0.019 for overall change with respect to the control group). The change in LFI (ΔLFI) at 12 months was -0.71 ± 0.24 in the intervention group and -0.09 ± 0.32 in the control group (p<0.001). During follow-up, patients in the intervention group had a lower 1-year probability of falls (6% vs. 47%, p = 0.03) and emergency room visits (10% vs. 44%, p = 0.04) than patients in the control group. CONCLUSIONS A long-term multifactorial intervention that included exercise at home, branched-chain amino acids, and a multistrain probiotic improved frailty in outpatients with cirrhosis and was associated with a decrease in the incidence of clinical events such as falls and emergency room visits.
Collapse
Affiliation(s)
- Eva Román
- University Nursing School EUI-Sant Pau, Barcelona, Spain
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Naujot Kaür
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Elisabet Sánchez
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
- Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Josep Padrós
- Department of Physical Medicine and Rehabilitation, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Maria Josep Nadal
- Department of Physical Medicine and Rehabilitation, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Berta Cuyàs
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Edilmar Alvarado
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Silvia Vidal
- Universitat Autònoma de Barcelona, Barcelona, Spain
- Institut de Recerca Sant Pau (IR Sant Pau), Barcelona, Spain
| | | | - Elvira Hernández
- University Nursing School EUI-Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rosalía Santesmases
- University Nursing School EUI-Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eulàlia Urgell
- Department of Biochemistry, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Elena Juanes
- Department of Pharmacy at Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Àngels Escorsell
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Carlos Guarner
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Germán Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
3
|
Xie R, Jing X, Yang C. The prevalence and characteristics of frailty in cirrhosis patients: a meta-analysis and systematic review. Front Med (Lausanne) 2024; 11:1353406. [PMID: 38745743 PMCID: PMC11092890 DOI: 10.3389/fmed.2024.1353406] [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: 12/10/2023] [Accepted: 03/08/2024] [Indexed: 05/16/2024] Open
Abstract
Objectives This study aimed to assess the prevalence of frailty in cirrhosis patients and the distribution of age, sex, and body mass index (BMI) in cirrhotic patients with frailty. Methods We performed a thorough literature search using PubMed, Embase, Web of Science, and the Cochrane Library from inception to 29 February 2024. The estimated prevalence with a 95% confidence interval (CI) was calculated with a random effect model. Subgroup analysis and sensitivity analysis were performed to assess the heterogeneity and characterize the distribution of age, sex, and body mass index (BMI) in cirrhotic patients. Publication bias was assessed by the funnel plot, Begg's test, and Egger's test. Results The 16 included studies, which were all observational, reported a prevalence of frailty in 8,406 cirrhosis patients ranging from 9 to 65%, and the overall estimated prevalence was 27% (95% CI: 21-33%; I2 = 97.7%, P < 0.001). This meta-analysis indicated that the estimated prevalence of frailty in cirrhosis patients was high, and compared to the non-frail cohort, the frail cohort tended to have a higher mean age, with a mean age of 63.3 (95% CI: 59.9, 66.7; Z = 36.48; P < 0.001), and a larger proportion of male patients with worse liver function, with a mean of 73.5% (95% CI: 71.4, 75.5%; Z = 7.65; P < 0.001), ND in the frail cohort, 54.8% (95% CI: 43.1, 66.5%; P < 0.001) and 23.4% (95% CI: 13.2, 33.7%; P < 0.001) were classified into Child-Pugh B and C, respectively. Meanwhile, the patients in the non-frail cohort are more likely to have a higher BMI, with a mean of 28.4 (95% CI: 24.1, 32.7; Z = 13.07; P < 0.001). Conclusion The current study suggests that cirrhosis patients have a high prevalence of frailty. Compared with the non-frail cohort, the frail patients tend to be male, older, and have a lower BMI with worse liver function.
Collapse
Affiliation(s)
- Ruiyu Xie
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Center for Digestive Diseases, Shijiazhuang, Hebei, China
| | - Xiaotong Jing
- Department of Hematology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Chuanjie Yang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Center for Digestive Diseases, Shijiazhuang, Hebei, China
| |
Collapse
|
4
|
Elsheikh M, El Sabagh A, Mohamed IB, Bhongade M, Hassan MM, Jalal PK. Frailty in end-stage liver disease: Understanding pathophysiology, tools for assessment, and strategies for management. World J Gastroenterol 2023; 29:6028-6048. [PMID: 38130738 PMCID: PMC10731159 DOI: 10.3748/wjg.v29.i46.6028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/08/2023] [Accepted: 12/01/2023] [Indexed: 12/13/2023] Open
Abstract
Frailty and sarcopenia are frequently observed in patients with end-stage liver disease. Frailty is a complex condition that arises from deteriorations across various physiological systems, including the musculoskeletal, cardiovascular, and immune systems, resulting in a reduced ability of the body to withstand stressors. This condition is associated with declined resilience and increased vulnerability to negative outcomes, including disability, hospitalization, and mortality. In cirrhotic patients, frailty is influenced by multiple factors, such as hyperammonemia, hormonal imbalance, malnutrition, ascites, hepatic encephalopathy, and alcohol intake. Assessing frailty is crucial in predicting morbidity and mortality in cirrhotic patients. It can aid in making critical decisions regarding patients' eligibility for critical care and transplantation. This, in turn, can guide the development of an individualized treatment plan for each patient with cirrhosis, with a focus on prioritizing exercise, proper nutrition, and appropriate treatment of hepatic complications as the primary lines of treatment. In this review, we aim to explore the topic of frailty in liver diseases, with a particular emphasis on pathophysiology, clinical assessment, and discuss strategies for preventing frailty through effective treatment of hepatic complications. Furthermore, we explore novel assessment and management strategies that have emerged in recent years, including the use of wearable technology and telemedicine.
Collapse
Affiliation(s)
- Mazen Elsheikh
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Ahmed El Sabagh
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Islam B Mohamed
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Megha Bhongade
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Manal M Hassan
- Department of Epidemiology, Division of Cancer Prevention and Population Sciences, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Prasun Kumar Jalal
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| |
Collapse
|
5
|
Deng Y, Hui Y, Cui B, Xie W, Sun C. Accumulating awareness on the clinical significance and relevance of frailty in cirrhosis: Time to dig deeper into mechanistic basis! Liver Int 2023; 43:1629-1643. [PMID: 37288711 DOI: 10.1111/liv.15639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 04/03/2023] [Accepted: 05/25/2023] [Indexed: 06/09/2023]
Abstract
Frailty corresponds to an emerging construct in the hepatology which is originally introduced as a validated geriatric syndrome regarding increased vulnerability to pathophysiological stressors. As for patients with cirrhosis, the presence of frailty is indicative of debilitating conditions that subjects are prone to deleterious acute insults and have difficulties to restore even if the underlying liver function partially returned to normal levels. Since this conceptual development, a variety of tools assessing frailty have been proposed and evaluated in the context of cirrhosis. A recent performance-based metric for frailty, designated as Liver Frailty Index, has broadly been applied in patients with cirrhosis and exhibited acceptable predictive ability in relation to disease progression, mortality and hospitalization. However, those functional tests measuring frailty may be impossible to perform in circumstance that patients are critically ill or undergoing detrimental events. An interesting modality indicates the use of alternative tests to evaluate frailty, which may be more adaptable and of choice for specific subgroups. The interrelation between frailty and various cirrhosis-associated pathological entities is of clinical importance and implication. Noticeably, it is imperative to clarify these complex linkages to highlight novel therapeutic targets or interventional endpoints. The efficient and effective management of frailty is still challenging, but many attempts have been made to overcome barriers of affordability and availability. Some clinical trials on small scale revealed that home-based exercise and individualized nutrition therapy show benefits in patients with cirrhosis, and high adherence to the treatment regimen may direct better efficacy and performance.
Collapse
Affiliation(s)
- You Deng
- Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Binxin Cui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Wen Xie
- Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| |
Collapse
|
6
|
Tandon P, Zanetto A, Piano S, Heimbach JK, Dasarathy S. Liver transplantation in the patient with physical frailty. J Hepatol 2023; 78:1105-1117. [PMID: 37208097 PMCID: PMC10825673 DOI: 10.1016/j.jhep.2023.03.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/23/2023] [Accepted: 03/26/2023] [Indexed: 05/21/2023]
Abstract
Frailty is a decline in functional reserve across multiple physiological systems. A key component of frailty is sarcopenia, which denotes a loss of skeletal muscle mass and impaired contractile function that ultimately result in physical frailty. Physical frailty/sarcopenia are frequent and contribute to adverse clinical outcomes before and after liver transplantation. Frailty indices, including the liver frailty index, focus on contractile dysfunction (physical frailty), while cross-sectional image analysis of muscle area is the most accepted and reproducible measure to define sarcopenia. Thus, physical frailty and sarcopenia are interrelated. The prevalence of physical frailty/sarcopenia is high in liver transplant candidates and these conditions have been shown to adversely impact clinical outcomes including mortality, hospitalisations, infections, and cost of care both before and after transplantation. Data on the prevalence of frailty/sarcopenia and their sex- and age-dependent impact on outcomes are not consistent in patients on the liver transplant waitlist. Physical frailty and sarcopenic obesity are frequent in the obese patient with cirrhosis, and adversely affect outcomes after liver transplantation. Nutritional interventions and physical activity remain the mainstay of management before and after transplantation, despite limited data from large scale trials. In addition to physical frailty, there is recognition that a global evaluation including a multidisciplinary approach to other components of frailty (e.g., cognition, emotional, psychosocial) also need to be addressed in patients on the transplant waitlist. Recent advances in our understanding of the underlying mechanisms of sarcopenia and contractile dysfunction have helped identify novel therapeutic targets.
Collapse
Affiliation(s)
- Puneeta Tandon
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED, University and Hospital of Padova, Padova, Italy
| | - Julie K Heimbach
- William J von Liebig Transplant Center Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, USA
| |
Collapse
|
7
|
Frailty as tested by the Liver Frailty Index in out-patient patients with cirrhosis in China: a cross-sectional study. Eur J Gastroenterol Hepatol 2023; 35:440-444. [PMID: 36538009 DOI: 10.1097/meg.0000000000002502] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND Early identification and prevention of frailty are very important for patients with cirrhosis. METHODS The study was the first to use Liver Frailty Index in out-patient patients with cirrhosis in China, and to analyze the influencing factors. RESULT This study included 387 patients with cirrhosis. Frailty was diagnosed using the Liver Frailty Index. Multiple Logistic regression model were used to analyze influencing factors of frailty in out-patient patients with cirrhosis. Frailty was diagnosed in 9.6% of patients and prefrailty was diagnosed in 54.8% of patients. Age, sex, BMI, education level, monthly economic income, number of unplanned hospital admissions in the past year, cause of cirrhosis, Child-Pugh classification of cirrhosis, nutritional risk, physical activity, gait speed and Activity of Daily Living (ADL) Scale in the frailty, prefrailty and no frailty of groups were statistically significant. Age (OR, 1.103; CI, 0.064-0.132), BMI (OR, 0.817; CI, -0.302 to -0.104), education level (OR, 4.321; CI, 0.754-2.173), physical activity (OR, 3.580; CI, 0.534-2.016) and gait speed (OR, 0.001; CI, -8.188 to -4.972) were influential factors of frailty in out-patient patients with cirrhosis. CONCLUSION Out-patient patients with cirrhosis have a high incidence of frailty and prefrailty. Elderly, reduced gait speed, no physical activity and low culture level are risk factors for frailty and prefrailty, and we should be identification and intervention early.
Collapse
|
8
|
Bowers SP, Brennan PN, Dillon JF. Systematic review: the role of frailty in advanced chronic liver disease. Aliment Pharmacol Ther 2023; 57:280-289. [PMID: 36433627 DOI: 10.1111/apt.17324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/13/2022] [Accepted: 11/11/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Frailty is a known predictor of outcome and mortality in patients undergoing liver transplantation. However, most patients remain unsuitable transplant candidates. It is not yet known if the assessment of frailty in non-transplant candidates can aid prognostication. AIM To collate and interrogate the various frailty tools presently used to predict mortality in the non-transplant cirrhosis setting. METHODS A comprehensive review of MEDLINE and EMBASE databases for articles published from inception to March 2022 was undertaken, excluding those where patients underwent transplantation or had hepatocellular carcinoma. RESULTS We identified 12 observational cohort studies, featuring 9 frailty indices. These were from various global healthcare settings and of fair or good quality. Most were objective tools utilising clinician-based assessments. All frailty scores predicted prognosis, with variability in the method of application, and utilisation in long- or short-term mortality. Three studies directly compared different indices in the same population. There was some evidence that simple tools could perform as well, if not better, than more complex, time-consuming scores. CONCLUSIONS Various frailty tools can reproducibly evaluate mortality in patients with cirrhosis who are ineligible for transplant. However, further prospective head-to-head comparative studies are needed. In addition to determining model utility, studies should focus on important relative considerations which may limit widespread implementation including, ease of use and limited resources, given the global disparity of liver care provision. These tools may positively identify specific patient cohorts at risk of impending deterioration, thereby stratifying those patients likely to benefit from early integration with palliative care.
Collapse
Affiliation(s)
- Sarah P Bowers
- NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
- Department of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Paul N Brennan
- Department of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
- Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, UK
| | - John F Dillon
- NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
- Department of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| |
Collapse
|
9
|
Li C, Zhao C, Yu Z, Yang W, Sun M, Li Y, Guo G, Hui Y, Wang X, Fan X, Wang B, Zhang J, Sun C. Low free triiodothyronine levels are associated with frail phenotype in hospitalized inpatients with cirrhosis. Postgrad Med 2022; 134:516-523. [PMID: 35382681 DOI: 10.1080/00325481.2022.2063487] [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] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Frailty is a prevalent complication predicting morbidity and mortality in cirrhosis. However, the association between thyroid hormone levels and frailty in cirrhotics remains elusive. Therefore we aimed to evaluate the relationship between thyroid hormone and frail phenotype in euthyroid patients with cirrhosis. METHODS A total of 214 adult cirrhotic inpatients were divided into two groups according to Frailty Index. Concentrations of free triiodothyronine (FT3), free thyroxine (FT4) and thyroid stimulating hormone (TSH) were compared. An analysis of the receiver operating characteristic (ROC) curve was implemented to determine the best cut-off for frailty. Multiple logistic regression was used to assess the association between FT3 and frailty. RESULTS ROC analysis indicated that the optimal cut-off to stratify frailty was FT3 <3.03 pmol/L with an area under the curve of 0.673 (95% CI: 0.582-0.764, p = 0.002), sensitivity of 81.8% and specificity of 51.9%. Patients with FT3 <3.03 pmol/L exhibited higher incidence of Child-Pugh class B/C, elevated model for end-stage liver disease score, higher creatinine, lower sodium as well as higher incidence of frailty (23.7 vs 6.0%, p < 0.001). A negative correlation was observed between FT3 values and Frailty Index (r = -0.220, p = 0.001). FT3 remained an independent risk factor for frailty after adjusting for age, Child-Pugh class, creatinine, sodium and alanine aminotransferase. CONCLUSION In our current study, FT3 <3.03 pmol/L were significantly associated with increased risk for frailty. Measuring FT3, a readily available biomarker, may be useful for identifying frail phenotype in euthyroid patients with cirrhosis.
Collapse
Affiliation(s)
- Chaoqun Li
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Department of Internal Medicine, Tianjin Hexi Hospital, Qiongzhou Road 43, Tianjin, Hexi District 300202, China
| | - Chunshan Zhao
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Zihan Yu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Wanting Yang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Mingyu Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Yifan Li
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Gaoyue Guo
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Xiaoyu Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Xiaofei Fan
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Bangmao Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Jie Zhang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, East Street 6, Tianjin Airport Economic Area, Tianjin 300308, China
| |
Collapse
|
10
|
Wang S, Whitlock R, Xu C, Taneja S, Singh S, Abraldes JG, Burak KW, Bailey RJ, Lai JC, Tandon P. Frailty is associated with increased risk of cirrhosis disease progression and death. Hepatology 2022; 75:600-609. [PMID: 34528267 DOI: 10.1002/hep.32157] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 08/03/2021] [Accepted: 08/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The Liver Frailty Index (LFI) is a well-studied tool that evaluates frailty in patients with cirrhosis. Consisting of grip strength, chair stands, and balance testing, the LFI has been associated with increased mortality in patients awaiting liver transplant. We aimed to extend our understanding of frailty in cirrhosis by exploring the relationship between the LFI and the risk of (1) cirrhosis progression, (2) mortality, and (3) unplanned hospitalizations, in both compensated and decompensated disease. APPROACH AND RESULTS Adult patients with cirrhosis from four centers in North America and one in India were included. Frailty was measured at baseline using the LFI and categorized as robust (LFI < 3.2), prefrail (LFI 3.2-4.5), and frail (LFI > 4.5). Progression of cirrhosis was defined by an increase in clinical stage, ranging from 1 to 5, from baseline using the D'Amico classification. Factors associated with progression, mortality, and hospitalizations were evaluated using multivariate regression models, with transplant as a competing risk. In total, 822 patients with cirrhosis were included. Average Model for End-Stage Liver Disease (MELD) score was 15.5 ± 6.0. In patients with compensated cirrhosis, being frail versus robust was associated with increased risk of progression to the next cirrhosis stage or to death (HR, 2.45; 95% CI, 1.14-5.29) and with an increased risk of unplanned hospitalizations (2.32; 95% CI, 1.13-4.79), after adjusting for age, sex, and MELD score. Similar HRs were observed in patients with decompensated cirrhosis. CONCLUSIONS Frailty was an independent predictor of cirrhosis progression or death and unplanned hospitalization across patients with compensated and decompensated cirrhosis. Future studies are needed to evaluate the possibility of slowing cirrhosis disease progression by reversing or preventing frailty.
Collapse
Affiliation(s)
- Sarah Wang
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Reid Whitlock
- Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Chelsea Xu
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surender Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Juan G Abraldes
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Kelly W Burak
- Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Robert J Bailey
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California, USA
| | - Puneeta Tandon
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
11
|
Mehta M, Louissaint J, Parikh NS, Long MT, Tapper EB. Cognitive Function, Sarcopenia, and Inflammation Are Strongly Associated with Frailty: A Framingham Cohort Study. Am J Med 2021; 134:1530-1538. [PMID: 34464599 PMCID: PMC9004665 DOI: 10.1016/j.amjmed.2021.07.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Frailty is an important contributor to morbidity and mortality in chronic liver disease. Understanding the contributors to frailty has the potential to identify individuals at risk for frailty and may potentially provide targets for frailty-modifying interventions. We evaluated the relationship among cognitive function, inflammation, and sarcopenia and frailty. METHODS Using cohorts from the Framingham Heart Study (2011-2014), we evaluated for factors associated with frailty. Exposures included cognitive tests (combined Trails A/B test, Animal Naming Test, and combined Digit Span Forward/Backward test), inflammation (interleukin-6 and tumor necrosis factor receptor II), and sarcopenia (creatinine-to-cystatin C ratio). We performed linear and logistic regression to identify the relationship between these exposures and the Liver Frailty Index (LFI). RESULTS The study population (N = 1208) had a median age of 70 years, was 56% female, and 48.5% had evidence of liver disease. The combined Trails A/B test (β 0.05, P < .001), creatinine-to-cystatin C (β -0.17, P = .006), and both inflammatory markers, interleukin-6 levels (β 0.16, P = .002) and tumor necrosis factor receptor II (β 0.21, P = .04), were independently associated with the LFI. Using an LFI cutoff of ≥4.5 to define frailty, Trails A/B (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.07-1.37), Animal Naming Test (OR 0.64, 95% CI 0.42-0.97), sarcopenia (OR 0.10, 95% CI 0.01-0.73), and interleukin-6 (OR 4.99, 95% CI 1.03-15.53) were all associated with frailty. Although liver disease did not modify the relationship between the LFI and the Trails A/B test, interleukin-6 was significantly associated with the LFI only in the presence of liver disease. CONCLUSIONS Cognitive performance, inflammation, and sarcopenia, each highly prevalent in cirrhosis, are associated with the LFI in this population-based study of persons without cirrhosis. Further research is warranted for interventions aiming to prevent frailty by tailoring their approach to the patient's underlying risk factors.
Collapse
Affiliation(s)
- Manaav Mehta
- University of California at Los Angeles, Los Angeles
| | - Jeremy Louissaint
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Cornell University, Ithaca, NY
| | - Michelle T Long
- Section of Gastroenterology, Boston University School of Medicine, Boston, Mass
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor.
| |
Collapse
|
12
|
Román E, Poca M, Amorós-Figueras G, Rosell-Ferrer J, Gely C, Nieto JC, Vidal S, Urgell E, Ferrero-Gregori A, Alvarado-Tapias E, Cuyàs B, Hernández E, Santesmases R, Guarner C, Escorsell À, Soriano G. Phase angle by electrical bioimpedance is a predictive factor of hospitalisation, falls and mortality in patients with cirrhosis. Sci Rep 2021; 11:20415. [PMID: 34650096 PMCID: PMC8516941 DOI: 10.1038/s41598-021-99199-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/06/2021] [Indexed: 12/13/2022] Open
Abstract
The phase angle is a versatile measurement to assess body composition, frailty and prognosis in patients with chronic diseases. In cirrhosis, patients often present alterations in body composition that are related to adverse outcomes. The phase angle could be useful to evaluate prognosis in these patients, but data are scarce. The aim was to analyse the prognostic value of the phase angle to predict clinically relevant events such as hospitalisation, falls, and mortality in patients with cirrhosis. Outpatients with cirrhosis were consecutively included and the phase angle was determined by electrical bioimpedance. Patients were prospectively followed to determine the incidence of hospitalisations, falls, and mortality. One hundred patients were included. Patients with phase angle ≤ 4.6° (n = 31) showed a higher probability of hospitalisation (35% vs 11%, p = 0.003), falls (41% vs 11%, p = 0.001) and mortality (26% vs 3%, p = 0.001) at 2-year follow-up than patients with PA > 4.6° (n = 69). In the multivariable analysis, the phase angle and MELD-Na were independent predictive factors of hospitalisation and mortality. Phase angle was the only predictive factor for falls. In conclusion, the phase angle showed to be a predictive marker for hospitalisation, falls, and mortality in outpatients with cirrhosis.
Collapse
Affiliation(s)
- Eva Román
- Escola Universitària d'Infermeria EUI-Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Mas Casanovas, 90, 08041, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Gerard Amorós-Figueras
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Javier Rosell-Ferrer
- Department of Electronic Engineering, Universitat Politècnica de Catalunya, Barcelona, Spain
| | | | - Juan C Nieto
- Research Institute IIB-Sant Pau, Barcelona, Spain
| | - Silvia Vidal
- Department of Immunology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- Research Institute IIB-Sant Pau, Barcelona, Spain
| | - Eulàlia Urgell
- Department of Biochemistry, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Andreu Ferrero-Gregori
- INCLIVA Health Research Institute, Valencia, Spain
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
| | - Edilmar Alvarado-Tapias
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Mas Casanovas, 90, 08041, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Berta Cuyàs
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - Elvira Hernández
- Escola Universitària d'Infermeria EUI-Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rosalia Santesmases
- Escola Universitària d'Infermeria EUI-Sant Pau, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Guarner
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Mas Casanovas, 90, 08041, Barcelona, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Àngels Escorsell
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Mas Casanovas, 90, 08041, Barcelona, Spain
| | - German Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Mas Casanovas, 90, 08041, Barcelona, Spain.
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain.
| |
Collapse
|
13
|
Siramolpiwat S, Kiattikunrat K, Soontararatpong R, Pornthisarn B, Vilaichone RK, Chonprasertsuk S, Bhanthumkomol P, Nunanun P, Issariyakulkarn N. Frailty as tested by the Liver Frailty Index is associated with decompensation and unplanned hospitalization in patients with compensated cirrhosis. Scand J Gastroenterol 2021; 56:1210-1219. [PMID: 34338110 DOI: 10.1080/00365521.2021.1957497] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Frailty is associated with morbidity and mortality in advanced cirrhosis. However, the information on the association between frailty and outcome in compensated cirrhosis is scarce. We aimed to explore the prognostic impact of frailty in compensated cirrhosis. METHODS Compensated cirrhotic patients were prospectively enrolled. Frailty was defined by the Liver Frailty Index (LFI). Development of new hepatic decompensation (worsening ascites, portal hypertension-related bleeding, hepatic encephalopathy, or acute kidney injury), unplanned hospitalization, and decompensation-free survival were recorded. Quality of life (QoL) was assessed by SF-36 questionnaire. RESULTS 152 patients were included (MELD 9.2 ± 3.4, Child-Pugh A/B 84.9%/15.1%), and 24.3% were frail. By multivariable logistic regression analysis, age > 65 years, MELD score > 10, and Child-Pugh B were associated with frailty. Compared to the robust group, pre-frail and frail patients had significantly higher cumulative 1-year probabilities of developing decompensation (0% vs. 8.5% vs. 18.4%, p = .009), and unplanned hospitalization (0% vs. 13.5% vs. 34.2%, p < .001), and lower 1-year decompensation-free survival (100% vs. 90.8% vs. 80.4%, p = .014). Two models of multivariable Cox regression analysis were done adjusted with MELD-Na and Child-Pugh B, frailty was associated with developing decompensation (HR 3.01, p = .04; and 2.98, p = .04, respectively) and unplanned hospitalization (HR 2.46, p = .02; and 2.39, p = .03, respectively), but not the decompensation-free survival. By multivariable linear regression analysis, Child-Pugh B and frailty significantly decreased both physical and mental component scores of the SF-36 questionnaire. CONCLUSION Frailty is prevalent in compensated cirrhosis. The LFI provides additional prognostic values to recognized risk scores regarding the development of decompensation, hospitalization, and impaired QoL.
Collapse
Affiliation(s)
- Sith Siramolpiwat
- Department of Medicine, Chulabhorn International College of Medicine (CICM), Thammasat University, Pathumthani, Thailand.,Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Keerati Kiattikunrat
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Ratikorn Soontararatpong
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Bubpha Pornthisarn
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Ratha-Korn Vilaichone
- Department of Medicine, Chulabhorn International College of Medicine (CICM), Thammasat University, Pathumthani, Thailand.,Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Soonthorn Chonprasertsuk
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Patommatat Bhanthumkomol
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Pongjarat Nunanun
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Navapan Issariyakulkarn
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| |
Collapse
|