Shining a spotlight on sarcopenia and myosteatosis in liver disease and liver transplantation: Potentially modifiable risk factors with major clinical impact

Muscle-wasting and disease-related malnutrition are highly prevalent in patients with chronic liver diseases (CLD) as well as in liver transplant (LT) candidates. Alterations of body composition (BC) such as sarcopenia, myosteatosis and sarcopenic obesity and associated clinical frailty were tied to inferior clinical outcomes including hospital admissions, length of stay, complications, mortality and healthcare costs in various patient cohorts and clinical scenarios. In contrast to other inherent detrimental individual characteristics often observed in these complex patients, such as comorbidities or genetic risk, alterations of the skeletal muscle and malnutrition are considered as potentially modifiable risk factors with a major clinical impact. Even so, there is only limited high-level evidence to show how these pathologies should be addressed in the clinical setting. This review discusses the current state-of-the-art on the role of BC assessment in clinical outcomes in the setting of CLD and LT focusing mainly on sarcopenia and myosteatosis. We focus on the disease-related pathophysiology of BC alterations. Based on these, we address potential therapeutic interventions including nutritional regimens, physical activity, hormone and targeted therapies. In addition to summarizing existing knowledge, this review highlights novel trends, and future perspectives and identifies persisting challenges in addressing BC pathologies in a holistic way, aiming to improve outcomes and quality of life of patients with CLD awaiting or undergoing LT.

Sarcopenia in cirrhosis: Unraveling the prevalence and relationships with liver disease severity and complications

BACKGROUND AND OBJECTIVES

Sarcopenia in cirrhosis is associated with poor survival and adverse pre and post-transplant outcomes. The study aimed at determining the prevalence of sarcopenia and its association with the severity, complications and etiology of liver disease.

METHODS

As many as 416 cirrhotic patients who met the inclusion criteria underwent muscle strength testing using a dynamometer. As many as 109 probable sarcopenia patients underwent computed tomography (CT) scan to measure skeletal muscle index (SMI) at the L3 vertebral level and gait-speed testing. The gender-specific cut-offs used to define sarcopenia were an SMI of 36.54 cm2/m2 in males and 30.21 cm2/m2 in females. A gait speed ≤ 0.8 m/s was taken as a cut-off to define severe sarcopenia in both genders.

RESULTS

The mean age was 54.7 ± 9.51 years and male:female ratio was 2.2:1.The mean body mass index (BMI) was 24.2 ± 1.34 kg/m2. Alcohol and non-alcoholic steatohepatitis (NASH) were the two most common etiologies (45.9% and 31.2%). The proportion of patients belonging to Child-Pugh class A, B and C was 26.6%, 48.6% and 24.8%, respectively. Forty out of 109 (36.7%) patients had a model for end-stage liver disease (MELD) > 14. Ascites, upper gastrointestinal bleeding and hepatic encephalopathy (HE) were present in 59 (54.1%), 60 (55.0%) and 24 (22.0%) patients, respectively. The prevalence of probable sarcopenia, sarcopenia and severe sarcopenia was found to be 26.20%, 10.09% and 6.73%, respectively. Sarcopenia and severe sarcopenia were associated with Child-Pugh class (p < 0.001, p < 0.001), MELD (p = 0.007, 0.002), upper gastrointestinal bleed (p = 0.007, 0.004), ascites (p = 0.038, 0.025) and HE (0.001, < 0.001).

CONCLUSION

The prevalence of sarcopenia and severe sarcopenia was found to be 10.09% and 6.73%, respectively. Sarcopenia and severe sarcopenia had a significant association with the severity and complications of cirrhosis. However, no association was observed with etiology of liver disease.

Portal Hypertension in Malnutrition and Sarcopenia in Decompensated Cirrhosis-Pathogenesis, Implications and Therapeutic Opportunities

Malnutrition and sarcopenia are highly prevalent in patients with decompensated cirrhosis and are associated with poorer clinical outcomes. Their pathophysiology is complex and multifactorial, with protein-calorie malnutrition, systemic inflammation, reduced glycogen stores and hormonal imbalances all well reported. The direct contribution of portal hypertension to these driving factors is however not widely documented in the literature. This review details the specific mechanisms by which portal hypertension directly contributes to the development of malnutrition and sarcopenia in cirrhosis. We summarise the existing literature describing treatment strategies that specifically aim to reduce portal pressures and their impact on nutritional and muscle outcomes, which is particularly relevant to those with end-stage disease awaiting liver transplantation.

Assessing the risk factors associated with sarcopenia in patients with liver cirrhosis: a case-control study

Sarcopenia is a disease characterized by decreased muscle mass and strength, affecting 20-70% of patients with cirrhosis, and is associated with poor prognosis, complications, and high mortality. At present, the epidemiological investigation of sarcopenia in patients with liver cirrhosis is relatively limited, and because of the differences in population characteristics, regions, diagnostic criteria and diagnostic tools, the prevalence of sarcopenia in various studies varies greatly. The definition of sarcopenia in this study adopted the criteria of the Asian Working Group on Sarcopenia (AWGS 2019), including muscle mass and muscle strength / physical performance. A total of 271 patients with liver cirrhosis were included in this cross-sectional study to explore the influencing factors of sarcopenia in patients with liver cirrhosis. The prevalence of sarcopenia was 27.7%, 27.3% in male and 28.4% in female. The results of binary logistic regression analysis showed that age, physical activity, BMI, mid-upper arm muscle circumference, hepatic encephalopathy, nutritional status, alkaline phosphatase, albumin and total cholesterol were significantly correlated with the occurrence of sarcopenia in patients with liver cirrhosis. After adjusting for the potential influencing factors, it was found that the correlation between age and sarcopenia was weakened (OR = 0.870, 95% CI 0.338-2.239). The current findings show that sarcopenia is common in patients with cirrhosis and is independently associated with age, physical activity, BMI, nutritional status, and albumin, and serum alkaline phosphatase and total cholesterol are associated with the development of sarcopenia. Regular exercise may help maintain the grip strength of patients with cirrhosis and delay the deterioration of liver function.

A prospective study on the differential association of sarcopenia and frailty with health outcomes in cirrhotic patients

BACKGROUND

To investigate the joint impact of sarcopenia and frailty on mortality and the development of decompensation in cirrhosis.

METHODS

Sarcopenia was assessed using the skeletal muscle mass index (SMI) by computed tomography, whereas frailty was measured using the Fried Frailty Phenotype (FFP). Cox proportional hazard regression and competing risks analysis were used to evaluate their association with adverse outcomes.

RESULTS

The prevalence of sarcopenia and frailty was 29.6% and 37.2%, respectively. Sarcopenia and frailty separately increased more than two times higher risk of all-cause mortality after adjustment for age, gender, Child-Turcotte-Pugh, and comorbidities. Co-occurrence of sarcopenia and frailty was associated with a higher incremental risk of mortality in patients with cirrhosis (HR = 4.16, 95% CI: 1.64-10.58, P = 0.003), but these two conditions didn't have significant interaction. Frailty, but not sarcopenia, was significantly associated with an increased cumulative incidence of liver-related mortality and decompensation after adjusting covariates. Subgroup analysis revealed that frailty shortened the liver-related survival of cirrhosis patients with male or higher liver severity based on MELD.

CONCLUSIONS

Co-occurrence of sarcopenia and frailty increased the risk of death in cirrhosis, but these two conditions didn't have a significant interaction association. Frailty, but not sarcopenia, was associated with more adverse outcomes in cirrhotic patients.

Liver transplantation in the patient with physical frailty

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.

Creatine Supplementation to Improve Sarcopenia in Chronic Liver Disease: Facts and Perspectives

Creatine supplementation has been one of the most studied and useful ergogenic nutritional support for athletes to improve performance, strength, and muscular mass. Over time creatine has shown beneficial effects in several human disease conditions. This review aims to summarise the current evidence for creatine supplementation in advanced chronic liver disease and its complications, primarily in sarcopenic cirrhotic patients, because this condition is known to be associated with poor prognosis and outcomes. Although creatine supplementation in chronic liver disease seems to be barely investigated and not studied in human patients, its potential efficacy on chronic liver disease is indirectly highlighted in animal models of non-alcoholic fatty liver disease, bringing beneficial effects in the fatty liver. Similarly, encephalopathy and fatigue seem to have beneficial effects. Creatine supplementation has demonstrated effects in sarcopenia in the elderly with and without resistance training suggesting a potential role in improving this condition in patients with advanced chronic liver disease. Creatine supplementation could address several critical points of chronic liver disease and its complications. Further studies are needed to support the clinical burden of this hypothesis.

Low skeletal muscle mass is associated with mortality in kidney transplant recipients

Muscle wasting in chronic kidney disease is associated with increased cardiovascular events, morbidity, and mortality. However, whether pretransplantation skeletal muscle mass affects kidney transplantation (KT) outcomes has not been established. We analyzed 623 patients who underwent KT between 2004 and 2019. We measured the cross-sectional area of total skeletal muscle at the third lumbar vertebra level on pretransplantation computed tomography scan. The patients were grouped into low and normal skeletal muscle mass groups based on the sex-specific skeletal muscle mass index lowest quartile. During the entire follow-up period, 45 patients (7.2%) died and 56 patients (9.0%) experienced death-censored graft loss. Pretransplantation low skeletal muscle mass was independently associated with all-cause mortality (adjusted hazard ratio, 2.269; 95% confidence interval, 1.232-4.182). Low muscle mass was also associated with an increased risk of hospital readmission within 1 year after transplantation. Death-censored graft survival rates were comparable between the 2 groups. The low muscle group showed higher creatinine-based estimated glomerular filtration rates (eGFRs) than the normal muscle group. Although cystatin C-based eGFRs were measured in only one-third of patients, cystatin C-based eGFRs were comparable between the 2 groups. Pretransplantation low skeletal muscle mass index is associated with an increased risk of mortality and hospital readmission after KT.

Improvement of sarcopenia is beneficial for prognosis in cirrhotic patients after TIPS placement

BACKGROUND

The relationship between the improvement of sarcopenia and post-TIPS prognosis has not been fully investigated.

AIMS

To assess what level of sarcopenia improvement is required for potential benefits to post-TIPS prognosis.

METHODS

In this retrospective study, 109 cirrhotic patients with sarcopenia who underwent TIPS between February 2016 and January 2021 were included. The change in skeletal muscle index (SMI) at 6 months post-TIPS was assessed and the correlations of SMI improvement with clinical outcomes were analyzed.

RESULTS

During follow up, 59 (65.6%) patients reversed from sarcopenic to non-sarcopenic, and the cumulative mortality (8.5 % vs. 26.0%, log rank P = 0.013) and incidence of overt hepatic encephalopathy (OHE) (18.6% vs. 44.0%, log rank P = 0.004) in patients who reversed were significantly lower than who did not. SMI improvement rate was identified as an independent risk factor for mortality and OHE. In addition, the cumulative survival rate of patients with sarcopenia reversal or SMI improvement rate > 10.4% was significantly higher than that of patients with an SMI improvement rate ≤ 10.4% (92.5% vs. 58.6%, log rank P < 0.001).

CONCLUSION

Reversal of sarcopenia or significant SMI improvement by TIPS could reduce the risk of death and OHE.

Effects of an active lifestyle on the physical frailty of liver transplant candidates

BACKGROUND

Liver transplantation is the most important therapeutic intervention for end-stage liver disease (ELD). The prioritization of these patients is based on the model for end-stage liver disease (MELD), which can successfully predict short-term mortality. However, despite its great validity and value, it cannot fully incorporate several comorbidities of liver disease, such as sarcopenia and physical frailty, variables that can sufficiently influence the survival of such patients. Subsequently, there is growing interest in the importance of physical frailty in regard to mortality in liver transplant candidates and recipients, as well as its role in improving their survival rates.

AIM

To evaluate the effects of an active lifestyle on physical frailty on liver transplant candidates.

METHODS

An observational study was performed within the facilities of the Department of Transplant Surgery of Aristotle University of Thessaloniki. Twenty liver transplant candidate patients from the waiting list of the department were included in the study. Patients that were bedridden, had recent cardiovascular incidents, or had required inpatient treatment for more than 5 d in the last 6 mo were excluded from the study. The following variables were evaluated: Activity level via the International Physical Activity Questionnaire (IPAQ); functional capacity via the 6-min walking test (6MWT) and cardiopulmonary exercise testing; and physical frailty via the Liver Frailty Index (LFI).

RESULTS

According to their responses in the IPAQ, patients were divided into the following two groups based on their activity level: Active group (A, 10 patients); and sedentary group (S, 10 patients). Comparing mean values of the recorded variables showed the following results: MELD (A: 12.05 ± 5.63 vs S: 13.99 ± 3.60; P > 0.05); peak oxygen uptake (A: 29.78 ± 6.07 mL/kg/min vs S: 18.11 ± 3.39 mL/kg/min; P < 0.001); anaerobic threshold (A: 16.71 ± 2.17 mL/kg/min vs S: 13.96 ± 1.45 mL/kg/min; P < 0.01); 6MWT (A: 458.2 ± 57.5 m vs S: 324.7 ± 55.8 m; P < 0.001); and LFI (A: 3.75 ± 0.31 vs S: 4.42 ± 0.32; P < 0.001).

CONCLUSION

An active lifestyle can be associated with better musculoskeletal and functional capacity, while simultaneously preventing the evolution of physical frailty in liver transplant candidates. This effect appears to be independent of the liver disease severity.

The psoas muscle depletion index is related to the degree of cirrhosis and skeletal muscle loss in patients with end-stage liver disease

Objective: To establish a new psoas muscle depletion index (PDI) from healthy young donors and to explore the correlation between the PDI and the severity of cirrhosis in patients with endstage liver disease (ESLD). Methods: Clinical data of 461 healthy donors were collected during the period 2014-2019, and clinical data of 331 patients with ESLD were collected during the period 2014-2018. The patients were divided into four groups by PDI severity: PDI ≥ 0.90, PDI = 0.75-0.90, PDI = 0.50-0.75 and PDI ≤ 0.50 (Gsev). Differences in international normalised ratio (INR), total bilirubin and serum creatinine levels, and Child-Pugh (CP) and model for end-stage liver disease (MELD) scores were compared. The sarcopenia incidence according to the PDI and the psoas muscle index (PMI) in different weight groups were also compared. Results: Gsev had the highest CP (10.2 ± 2.1) and MELD (20.1 ± 7.4) scores and total bilirubin (166.3 ± 192.0 umol/L) and blood creatinine (92.9 ± 90.2 umol/L) levels and the lowest haemoglobin (93.8 ± 21.7 g/L) and blood albumin (30.9 ± 5.8 g/L) levels. Gsev showed significant changes in INR (1.74 ± 0.65) and blood sodium (135.3 ± 5.65 mmol/L). If PDI <0.75 was used as the diagnostic criterion for sarcopenia, the incidence was 53.3% in patients weighing >90 kg and 53.6% in those weighing <60 kg. This differed from the PMI, with an incidence of 3.3% in patients weighing >90 kg. Conclusions: The PDI had no significant correlation with body height, body weight or body mass index (BMI) in healthy individuals and patients with ESLD. The PDI was significantly correlated with the severity of cirrhosis and loss of skeletal muscle.

Prevalence of Low Muscle Mass in the Computed Tomography at the Third Lumbar Vertebra Level Depends on Chosen Cut-Off in 200 Hospitalised Patients-A Prospective Observational Trial

Measuring skeletal muscle area (SMA) at the third lumbar vertebra level (L3) using computed tomography (CT) is increasingly popular for diagnosing low muscle mass. The aim was to describe the effect of the CT L3 cut-off choice on the prevalence of low muscle mass in medical and surgical patients. Two hundred inpatients, who underwent an abdominal CT scan for any reason, were included. Skeletal muscle area (SMA) was measured according to Hounsfield units on a single CT scan at the L3 level. First, we calculated sex-specific cut-offs, adjusted for height or BMI and set at mean or mean-2 SD in our population. Second, we applied published cut-offs, which differed in statistical calculation and adjustment for body stature and age. Statistical calculation of the cut-off led to a prevalence of approximately 50 vs. 1% when cut-offs were set at mean vs. mean-2 SD in our population. Prevalence varied between 5 and 86% when published cut-offs were applied (p < 0.001). The adjustment of the cut-off for the same body stature variable led to similar prevalence distribution patterns across age and BMI classes. The cut-off choice highly influenced prevalence of low muscle mass and prevalence distribution across age and BMI classes.

Sarcopenia in chronic advanced liver diseases: A sex-oriented analysis of the literature

Sarcopenia, defined as progressive and generalized loss of muscle mass and strength, is common in chronic liver disease. It significantly impacts the quality of life and increases the risk of liver-related complications and mortality in cirrhotic patients. Moreover, recent studies showed a negative impact of sarcopenia on patients awaiting liver transplantation (LT), on post-LT outcomes, and on response to hepatocellular carcinoma therapies. Data about the influence of sex on the incidence, prevalence, diagnosis and treatment of sarcopenia in chronic liver diseases are poor and conflicting. The aims of this review of the literature are to define sex differences in sarcopenic cirrhotic patients and to highlight the necessity of a sex stratified analysis in future studies. This analysis of the literature showed that most of the studies are retrospective, with a higher prevalence of sarcopenia in males, probably due to anatomical differences between the sexes. Moreover, diagnostic criteria for sarcopenia are different between studies, as there is not a defined cut-off and, as a consequence, no comparable results. In conclusion, sex seems to have an impact on sarcopenia, and future studies must accurately investigate its role in identifying and treating high-risk patients, reducing the negative impact of sarcopenia on the survival and quality of life of cirrhotic patients.

State of Knowledge on Molecular Adaptations to Exercise in Humans: Historical Perspectives and Future Directions

For centuries, regular exercise has been acknowledged as a potent stimulus to promote, maintain, and restore healthy functioning of nearly every physiological system of the human body. With advancing understanding of the complexity of human physiology, continually evolving methodological possibilities, and an increasingly dire public health situation, the study of exercise as a preventative or therapeutic treatment has never been more interdisciplinary, or more impactful. During the early stages of the NIH Common Fund Molecular Transducers of Physical Activity Consortium (MoTrPAC) Initiative, the field is well-positioned to build substantially upon the existing understanding of the mechanisms underlying benefits associated with exercise. Thus, we present a comprehensive body of the knowledge detailing the current literature basis surrounding the molecular adaptations to exercise in humans to provide a view of the state of the field at this critical juncture, as well as a resource for scientists bringing external expertise to the field of exercise physiology. In reviewing current literature related to molecular and cellular processes underlying exercise-induced benefits and adaptations, we also draw attention to existing knowledge gaps warranting continued research effort. © 2021 American Physiological Society. Compr Physiol 12:3193-3279, 2022.

Prevalence of sarcopenia in community dwelling outpatient postmenopausal Hungarian women

Background

Ageing is an inherent feature of life and as per the United Nations, in the year 2020, 985 million women were ≥ 50 years of age worldwide, and the figure is expected to rise to 1.65 billion by 2050. Preservation of health and well-being in the elderly are challenging, and on the same note generalized changes in the musculoskeletal system contribute to this scenario. Musculoskeletal changes with ageing are referred to as sarcopenia. Reduced muscle mass and physical performance are hallmarks of sarcopenia, exclaimed with difficulty in independent activity and poor quality of life. Knowing that there is a hiatus in our knowledge as regards to the prevalence of sarcopenia in Hungary, the aim of this study was to determine the prevalence of sarcopenia in a community dwelling outpatient postmenopausal Hungarian cohort using the EWGSOP2 consensus recommendation.

Methods

In this cross-sectional study, women arriving for routine bone densitometry examination at the Regional Osteoporosis Center, Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen were invited to participate in the study. A total of a 100 community-dwelling women were recruited who confirmed to the inclusion criteria of self-reported postmenopausal status, ≥ 50 years of age and gave written informed consent. The study procedures included the self-administered SARC-F questionnaire, followed by assessment of muscle strength, muscle quantity and physical preformance. Muscle strength was determined with the hand grip strength (HGS), appendicular skeletal muscle mass was assessed using dual energy X-ray absorptiometry and physical performance was determined by the gait speed (GS) test.

Results

As per the EWGSOP2 definition, the percentage of study participants with probable sarcopenia (low muscle strength), sarcopenia (low muscle strength and low muscle quantity) and severe sarcopenia (low muscle strength, muscle quantity and low physical performance) was 36, 31 and 8%, respectively. Multiple linear regression analysis revealed that height, weight, HGS and GS were all independent predictors of appendicular skeletal muscle mass.

Conclusion

The 31% prevalence of sarcopenia in the studied post-menopausal women highlights the need for adequate assessment of the condition in the elderly. Our findings most probably bear public health implications and may accelerate formulation of policies promoting healthy ageing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05167-2.

Impact of Sarcopenia on the Severity of the Liver Damage in Patients With Non-alcoholic Fatty Liver Disease

An extensive body of the literature shows a strong interrelationship between the pathogenic pathways of non-alcoholic fatty liver disease (NAFLD) and sarcopenia through the muscle-liver-adipose tissue axis. NAFLD is one of the leading causes of chronic liver diseases (CLD) affecting more than one-quarter of the general population worldwide. The disease severity spectrum ranges from simple steatosis to non-alcoholic steatohepatitis (NASH), cirrhosis, and its complications: end-stage chronic liver disease and hepatocellular carcinoma. Sarcopenia, defined as a progressive loss of the skeletal muscle mass, reduces physical performances, is associated with metabolic dysfunction and, possibly, has a causative role in NAFLD pathogenesis. Muscle mass is a key determinant of the whole-body insulin-mediated glucose metabolism and impacts fatty liver oxidation and energy homeostasis. These mechanisms drive the accumulation of ectopic fat both in the liver (steatosis, fatty liver) and in the muscle (myosteatosis). Myosteatosis rather than the muscle mass per se, seems to be closely associated with the severity of the liver injury. Sarcopenic obesity is a recently described entity which associates both sarcopenia and obesity and may trigger worse clinical outcomes including hepatic fibrosis progression and musculoskeletal disabilities. Furthermore, the muscle-liver-adipose tissue axis has a pivotal role in changes of the body composition, resulting in a distinct clinical phenotype that enables the identification of the "sarcopenic NAFLD phenotype." This review aims to bring some light into the complex relationship between sarcopenia and NAFLD and critically discuss the key mechanisms linking NAFLD to sarcopenia, as well as some of the clinical consequences associated with the coexistence of these two entities: the impact of body composition phenotypes on muscle morphology, the concept of sarcopenic obesity, the relationship between sarcopenia and the severity of the liver damage and finally, the future directions and the existing gaps in the knowledge.

European Working Group on Sarcopenia in Older People (EWGSOP2) Criteria With Population-Based Skeletal Muscle Index Best Predicts Mortality in Asians With Cirrhosis

BACKGROUND/AIMS

Multiple definitions of sarcopenia exist and the acceptable criterion that best predicts outcome is lacking. We estimated the prevalence of sarcopenia based on four criteria and assessed their utility in predicting mortality in cirrhotics.

METHODS

In a prospective observational study, consecutive Asian patients with cirrhosis underwent testing for handgrip strength (HGS) and estimation of skeletal muscle index (SMI) using computed tomography at the third lumbar vertebra. Sarcopenia was defined based on the Western cut-off (WC; SMI < 50 cm²/m² for men and <39 cm²/m² for women), Asian cut-off (AC; SMI < 36.5 cm²/m² for men and 30.2 cm²/m² for women), European Working Group on Sarcopenia in Older People-2nd meeting (EWGSOP2) definition incorporating low HGS (<27 kg for men and <16 kg for women) with low SMI (defined by the WC), and EWGSOP2 definition with low HGS and low SMI (defined by AC). Risk factors for mortality were assessed using multivariate Cox-proportional hazards.

RESULTS

We included 219 patients with cirrhosis (168 men; mean age 42.6 years) with 50.2% patients having decompensation. Alcohol was the commonest aetiology (33.3%). The prevalence of sarcopenia was highest with the WC (men: 82.1%; women: 62.7%). There was a weak concordance among all criteria (Fleiss' kappa 0.23, 95% confidence interval [CI] 0.10-0.37). Overall, 12-month survival was 86.1% (81.1-91.3%) over a median (interquartile range) follow-up of 12 (6-15) months. Ascites (hazards ratio [HR] 6.27 [95% CI 1.6-24.1]; P < 0.007) and SMI (HR 0.92 [0.85-0.98]; P = 0.021) were independent predictors of mortality. The 12-month mortality rate was higher in patients with sarcopenia, irrespective of criteria (log rank P < 0.05). Low HGS and low SMI (defined by AC) was the best for predicting mortality (HR 3.04 [1.43-6.43]; P = 0.004).

CONCLUSION

A weak concordance exists amongst various diagnostic definitions of sarcopenia. Sarcopenia diagnosed by a combination of low HGS and population-specific SMI cut-off (AC) best predicts mortality.

The improvement in body composition including subcutaneous and visceral fat reduces ammonia and hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

BACKGROUND

Sarcopenia and myosteatosis have been associated to a poor prognosis of cirrhosis and to a higher incidence of hepatic encephalopathy (HE). The prognostic implications of visceral and subcutaneous adiposity are less known.

AIM

To evaluate the modifications of visceral and subcutaneous adipose tissue after TIPS and to investigate their relationships with the modification of muscle mass and with the incidence of post-TIPS HE.

PATIENTS AND METHODS

35 cirrhotic patients submitted to TIPS were retrospectively studied. The modification of skeletal muscle index (SMI), muscle attenuation (myosteatosis), subcutaneous adipose tissue index (SATI), visceral adipose tissue index (VATI), assessed by CT-scan and plasma ammonia were evaluated before and after a mean follow-up of 19 ± 15 months after TIPS. The number of episodes of overt HE was also recorded.

RESULTS

During the follow-up, the mean SMI and muscle attenuation increased significantly; SATI significantly increased while VATI significantly decreased, although not uniformly in all patients. By comparing the patients with or without improvement in their nutritional status after TIPS, MELD remained stable while the number of episodes of overt HE was significantly lower in the patients with improved SMI and in the patients with improved SATI. Finally, inverse correlation was observed between the variation of ammonia and SATI (r = -.40; P < .05).

CONCLUSION

In addition to muscle mass, adipose tissue is modified after TIPS. The improvement of subcutaneous adipose tissue as well as of sarcopenia and myosteatosis is associated to the amelioration of cognitive impairment independently of liver function. The correlation between adipose tissue and ammonia modification may suggest an active role of the adipose tissue in the inter-organ ammonia trafficking.

Sarcopenia affects activities of daily living recovery and hospitalization costs in older adults in convalescent rehabilitation wards

PURPOSE

This study aimed to investigate the impact of sarcopenia on activities of daily living (ADL) recovery and hospitalization costs in older patients admitted to convalescent rehabilitation wards.

METHODS

This prospective cohort study included 104 patients aged ≥ 65 years who were admitted to convalescent rehabilitation wards. The primary outcome was ADL recovery as evaluated by the Functional Independence Measure (FIM) efficiency during hospitalization, and the secondary outcome was hospital-related costs. Univariate and multivariate analyses were performed to identify whether sarcopenia was associated with FIM-motor efficiency and hospitalization costs.

RESULTS

Among the patients, 68.3% were females, and the mean age was 82.3 ± 8.3 years. The prevalence of sarcopenia was 73.1%. The FIM-motor efficiency score was significantly lower in patients with sarcopenia (median 0.38; interquartile range 0.27-0.52) than in those without sarcopenia (median 0.55; interquartile range 0.34-0.87) (P = 0.009). Hospitalization costs were higher in patients with sarcopenia (32,813 ± 15,184 dollars) than in those without sarcopenia (26,879 ± 10,248 dollars) (P = 0.058). Multivariate analysis showed that sarcopenia was independently associated with FIM-motor efficiency (standardized β =  - 0.236, P = 0.014, R2 = 0.40) and hospitalization costs (standardized β = 0.15, P = 0.027, R2 = 0.70) after adjusting for confounding factors.

CONCLUSION

We found that sarcopenia reduces the FIM-motor efficiency and increases direct hospitalization costs in older patients admitted to convalescent rehabilitation wards. Therefore, it is necessary to design interventions to prevent sarcopenia and improve the efficiency of ADL recovery and reduce direct hospitalization cost.

Myostatin in combination with creatine phosphokinase or albumin may differentiate patients with cirrhosis and sarcopenia

In patients with liver cirrhosis (LC), sarcopenia is correlated with frequent complications and increased mortality. Myostatin, a myokine, is a potential biomarker of skeletal mass and/or sarcopenia. The aim of this study was to examine the association between myostatin and muscle mass and evaluate myostatin as a biomarker of sarcopenia in LC. Skeletal muscle index (SMI) and myosteatosis were evaluated by computed tomography scan. Muscle quantity and quality along with muscle strength and function were used to diagnose sarcopenia. Serum myostatin was measured by ELISA. One hundred and fifteen consecutive patients with LC [72.2% male, median age 59 yr (IQR 52-67), MELD 12 (8-16), 28.7% with compensated LC] were included. Low SMI was diagnosed in 49.6% and sarcopenia in 34.8% (21.7% severe). Myostatin levels were lower in low (P < 0.001) compared with patients with normal SMI and were strongly correlated with SMI in MELD score ≥ 15 (r = 0.571, P < 0.001). Myostatin was also lower in patients with sarcopenia compared with those without (P < 0.001) and even lower in severe sarcopenia (P < 0.001). In multivariate analysis, myostatin, age, and albumin remained significant predictors of low SMI after adjustment for sex, MELD, and creatine phosphokinase (CPK). Similarly, myostatin and age predicted sarcopenia after adjustment for sex, MELD, CPK, and albumin. The ratios log₁₀myostatin-to-CPK or albumin-to-myostatin were found to have acceptable diagnostic accuracy in ruling out sarcopenia in total patients. However, the best diagnostic performance was shown in MELD ≥ 15 (AUROC 0.829 or 0.801, respectively). Myostatin is independently associated with both skeletal muscle mass and sarcopenia. Myostatin in combination with CPK or albumin are good surrogate markers in excluding sarcopenia.NEW & NOTEWORTHY Serum levels of myostatin were significantly lower in cirrhotic patients with impaired skeletal mass index (SMI) and sarcopenia than those without. Serum levels of myostatin have a positive correlation with SMI. Myostatin levels are independently associated with sarcopenia, diagnosed according to the latest criteria, in patients with cirrhosis. Myostatin in combination with creatine phosphokinase or albumin have good accuracy excluding sarcopenia in patients with cirrhosis.

Physical frailty in liver transplantation

In patients with cirrhosis, frailty represents a status of global physical dysfunction associated with a multiplicity of factors, including muscle wasting, undernutrition and malnutrition, and functional impairment. This condition is particularly prevalent among those with advanced cirrhosis, such as liver transplant (LT) candidates. Studies in this vulnerable population have demonstrated that its presence is independently predictive of adverse outcomes both pre- and post-transplantation, and thus that its incorporation into clinical practice could result in improved clinical decision-making, particularly regarding the identification of candidates for physical and nutritional interventions. There are, however, some limitations to its immediate incorporation into organ allocation prioritization models, including the wide heterogeneity of instruments used for measuring frailty, and particularly the lack of a single one suitable in all LT clinical scenarios (inpatient vs outpatient; pre- vs post-transplant). Finally, the data on the potential effects of frailty improvement on the diverse range of outcome measures are still preliminary.

Impact of sarcopenia on clinical outcomes of patients undergoing simultaneous liver and kidney transplantation: a cohort study

BACKGROUND

The impact of sarcopenia in patients undergoing simultaneous liver and kidney transplantation (SLKT) has not been fully delineated. The aim of this single-centre-cohort-study was to evaluate the impact of sarcopenia on the clinical outcomes.

METHODS

Between 2003 and 2018, 79 patients underwent SLKT. Sarcopenia was assessed via the total psoas muscle area (TPA) at the level of the 3rd. lumbar vertebra. Sarcopenia threshold was TPA < 1460 mm² (women) and <1560 mm² (men). We identified post-operative biliary, vascular and digestive complications. Survival analysis was performed by the Kaplan Meier method (log-rank test).

RESULTS

We included 43/79 SLKT recipients (56%male, median age of 58 [53-63] years). The prevalence of cirrhosis was 74% (n = 32) with median MELD-score of 21 (20-22) and that of polycystic-liver-disease was 26% (n = 11). End-stage-renal-disease of unknown origin was 36.2% (n = 12). Dialysis before transplantation was performed in 54,8% (n = 23) of patients. The median TPA was 1138 (926-1510) mm², and sarcopenia was detected in 72% of patients (n = 31). No difference in patient or death-censored graft-survival between sarcopenic and non-sarcopenic groups at 1 year was reported. Also, no differences at 6-months' post-transplant-complication-free and infection-free-survival rates were found.

CONCLUSION

In this cohort of patients, no differences were observed in patients, grafts, complications or infection-free survival between sarcopenic or no sarcopenic SLKT patients. Future multi-centre studies are needed to validate and extend the generalisability of these findings.

Tale of the Frail: Understanding Frailty in Cirrhosis

Frailty is a dynamic condition that results in increased vulnerability to health stressors. Often associated with older adults, frailty is not limited to the geriatric population, although aging and disease burden often go hand in hand. This syndrome is recognized increasingly as an important factor in healthcare costs, rate of adverse outcomes, and overall resource utilization. Frailty may be reversible to a degree, and thus appropriate recognition affords a focus for efficient intervention. Notably, frailty is becoming increasingly relevant in cirrhosis, and has been noted to be an independent predictor of outcomes in patients both before and after liver transplantation. Cirrhosis is currently the 12th leading cause of death in the United States, and its incidence is anticipated to markedly increase in the coming years with the aging of our population. With the anticipated surge in disease prevalence, liver disease care will likely shift from specialist-driven to a multidisciplinary approach between primary care physicians, internists, and hepatologists to adequately care for these patients. This review serves as a guide for clinicians to learn about frailty, its role in cirrhosis, and the current tools to educate patients and families about the importance of nutrition and physical exercise within this population.

Frailty as a predictive factor for survival after liver transplantation, especially for patients with MELD≤15-a prospective study

Introduction

Frailty has been discussed as a predictor of morbidity and mortality for liver cirrhosis. The aim of our study is to evaluate the role of frailty in liver transplantation, particularly for patients with MELD scores < 15.

Methods

All patients listed for liver transplantation between September 2015 and November 2018 were prospectively included in the study. Frailty was assessed by Fried’s frailty classification. Pre-, intra-, and postoperative data were prospectively recorded. Univariate and multivariate regression analyses were performed. The ethical approval of the institutional board review was obtained for the study.

Results

There were 114 patients included in the study, and their median MELD score was 16. Of these, 86 patients were defined as frail (75.4%). A total of 62 patients (54.4%) underwent liver transplantation, 11 (17.7%) died postoperatively, and 24 patients (21.0%) died while on the waitlist. All postoperative mortality cases were frail, and only 3 patients (12.5%) were non-frail in the waitlist mortality group. There were 14 patients who had MELD scores of <15 (58.3%). The overall survival of non-frail patients was significantly better than that of frail patients. The multivariate regression analyses identified frailty criteria, including unintended weight loss and low hand grip strength, and platelet count and being married or living in a solid partnership were prognostic factors for survival in all patients.

Conclusion

The addition of frailty assessment can be beneficial for predicting mortality after liver transplantation, especially in patients with low MELD score. Frail patients on the waitlist have significant risk for mortality even with low MELD score.

Clinical impact of sarcopenia assessment in patients with liver cirrhosis

Introduction: Sarcopenia is defined as loss of skeletal muscle mass, strength, and function, and it is associated with increased morbidity and mortality in patients with chronic liver disease.Areas covered: The aim of this review is to provide a detailed report on the pathophysiological mechanisms underlying sarcopenia in cirrhotic patients, the several imaging methods available for the assessment of sarcopenia and the clinical studies evaluating the prognostic role of sarcopenia presence in cirrhotic patients.Expert opinion: Sarcopenia pathogenesis is complex and multifaceted, as chronic catabolic conditions, increased energy expenditure, reduced appetite, side effects of multiple therapies, alterations in circulating levels of hormones, low protein synthesis, presence of ascites or portosystemic shunts are all factors contributing to muscle atrophy in cirrhotic patients. Computed tomography scan is the most validated method to evaluate muscle mass and quality. Sarcopenia is associated with a higher rate waitlist mortality, hepatic encephalopathy, and lower quality of life in patients with liver cirrhosis. Future studies should make an effort to unify and validate liver disease-specific cutoffs for the definition of sarcopenia.

Emerging Treatment Options for Sarcopenia in Chronic Liver Disease

Sarcopenia is characterized by a skeletal muscle disorder with progressive and generalized loss of muscle mass and function, and it increases the risk of adverse outcomes with considerable prevalence in patients with chronic liver disease. Sarcopenia in chronic liver disease underlies complicated and multifactorial mechanisms for pathogenesis, including alterations in protein turnover, hyperammonemia, energy disposal, hormonal changes, and chronic inflammation. The key contribution to sarcopenia in patients with chronic liver diseases can be the hyperammonemia-induced upregulation of myostatin, which causes muscle atrophy via the expression of atrophy-related genes. Several clinical studies on emerging treatment options for sarcopenia have been reported, but only a few have focused on patients with chronic liver diseases, with mostly nutritional and behavioral interventions being carried out. The inhibition of the myostatin-activin receptor signaling pathway and hormonal therapy might be the most promising therapeutic options in combination with an ammonia-lowering approach in sarcopenic patients with chronic liver diseases. This review focuses on current and emerging treatment options for sarcopenia in chronic liver diseases with underlying mechanisms to counteract this condition.

Sarcopenia in chronic liver disease: mechanisms and countermeasures

Sarcopenia, a condition of low muscle mass, quality, and strength, is commonly found in patients with cirrhosis and is associated with adverse clinical outcomes including reduction in quality of life, increased mortality, and posttransplant complications. In chronic liver disease (CLD), sarcopenia is most commonly defined through the measurement of the skeletal muscle index of the third lumbar spine. A major contributor to sarcopenia in CLD is the imbalance in muscle protein turnover, which likely occurs due to a decrease in muscle protein synthesis and an elevation in muscle protein breakdown. This imbalance is assumed to arise due to several factors including accelerated starvation, hyperammonemia, amino acid deprivation, chronic inflammation, excessive alcohol intake, and physical inactivity. In particular, hyperammonemia is a key mediator of the liver-gut axis and is known to contribute to mitochondrial dysfunction and an increase in myostatin expression. Currently, the use of nutritional interventions such as late-evening snacks, branched-chain amino acid supplementation, and physical activity have been proposed to help the management and treatment of sarcopenia. However, little evidence exists to comprehensively support their use in clinical settings. Several new pharmacological strategies, including myostatin inhibition and the nutraceutical Urolithin A, have recently been proposed to treat age-related sarcopenia and may also be of use in CLD. This review highlights the potential molecular mechanisms contributing to sarcopenia in CLD alongside a discussion of existing and potential new treatment strategies.

Compound Sarcopenia in Hospitalized Patients with Cirrhosis Worsens Outcomes with Increasing Age

Background: There are limited data on outcomes of older patients with chronic diseases. Skeletal muscle loss of aging (primary sarcopenia) has been extensively studied but the impact of secondary sarcopenia of chronic disease is not as well evaluated. Older patients with chronic diseases have both primary and secondary sarcopenia that we term compound sarcopenia. We evaluated the clinical impact of compound sarcopenia in hospitalized patients with cirrhosis given the increasing number of patients and high prevalence of sarcopenia in these patients. Design: The Nationwide Inpatients Sample (NIS) database (years 2010–2014) was analyzed to study older patients with cirrhosis. Since there is no universal hospital diagnosis code for “muscle loss”, we used a comprehensive array of codes for “muscle loss phenotype” in the international classification of diseases-9 (ICD-9). A randomly selected 2% sample of hospitalized general medical population (GMP) and inpatients with cirrhosis were stratified into 3 age groups based on age-related changes in muscle mass. In-hospital mortality, length of stay (LoS), cost of hospitalization (CoH), comorbidities and discharge disposition were analyzed. Results. Of 517,605 hospitalizations for GMP and 106,835 hospitalizations for treatment of cirrhosis or a cirrhosis-related complication, 207,266 (40.4%) GMP and 29,018 (27.7%) patients with cirrhosis were >65 years old, respectively. Muscle loss phenotype in both GMP and inpatients with cirrhosis 51–65 years old and >65 years old was significantly (p < 0.001 for all) associated with higher mortality, LoS, and CoH compared to those ≤50 years old. Patients >65 years old with cirrhosis and muscle loss phenotype had higher mortality (adjusted OR: 1.06, 95% CI [1.04, 1.08] and CoH (adjusted odds ratio (OR): 1.10, 95% confidence interval (CI) [1.04, 1.08])) when compared to >65 years old GMP with muscle loss phenotype. Muscle loss in younger patients with cirrhosis (≤50 years old) was associated with worse outcomes compared to GMP >65 years old. Non-home discharges (nursing, skilled, long-term care) were more frequent with increasing age to a greater extent in patients with cirrhosis with muscle loss phenotype for each age stratum. Conclusion: Muscle loss is more frequent in older patients with cirrhosis than younger patients with cirrhosis and older GMP. Younger patients with cirrhosis had clinical outcomes similar to those of older GMP, suggesting an accelerated senescence in cirrhosis. Compound sarcopenia in older patients with cirrhosis is associated with higher inpatient mortality, increased LoS, and CoH compared to GMP with sarcopenia.

The Clinical Impact of Cirrhosis on the Hospital Outcomes of Patients Admitted With Influenza Infection: Propensity Score Matched Analysis of 2011-2017 US Hospital Data

BACKGROUND/OBJECTIVES

Patients with cirrhosis have liver-related immune dysfunction that potentially predisposes the patients to increased influenza infection risk. Our study evaluates this cross-sectional relationship using a national registry of hospital patients.

METHODS

This study included the 2011-2017 National Inpatient Sample database. From this, respiratory influenza cases were isolated and stratified using the presence of cirrhosis into a cirrhosis-present study cohort and cirrhosis-absent controls; propensity score matching method was used to match the controls to the study cohort (cirrhosis-present) using a 1:1 matching ratio. The endpoints included mortality, length of stay, hospitalization costs, and influenza-related complications.

RESULTS

Following the match, there were 2,040 with cirrhosis and matched 2,040 without cirrhosis admitted with respiratory influenza infection. Compared to the controls, cirrhosis patients had higher in-hospital mortality (7.79 vs 3.43% p < 0.001, OR 2.38 95% CI 1.78-3.17), longer length of stay (7.25 vs 6.52 d p < 0.001), higher hospitalization costs ($70,009 vs $65,035 p < 0.001), and were more likely be discharged to a skilled nursing facility and home healthcare (vs routine home discharges). In terms of influenza-related complications, the cirrhosis cohort had higher rates of sepsis (29.8 vs 22% p < 0.001, OR 1.51 95% CI 1.31-1.74). In the multivariate regression analysis, cirrhosis was associated with higher mortality (p < 0.001, aOR 2.31 95% CI 1.59-3.35) and length of stay (p = 0.018, aOR 1.03 95% CI 1.01-1.06). In subgroup analysis of patients with decompensated (n = 597) versus compensated cirrhosis (n = 1443), those with decompensated cirrhosis had higher rates of in-hospital mortality (12.7 vs 5.75% p < 0.001, OR 2.39 95% CI 1.72-3.32), length of stay (8.85 vs 6.59 d p < 0.001), and hospitalization costs ($92,858 vs $60,556 p < 0.001). In the multivariate analysis, decompensated cirrhosis was associated with increased mortality (p < 0.001, aOR 2.86 95% CI 1.90-4.32).

CONCLUSION

This study shows the presence of cirrhosis to result in higher hospital mortality and postinfluenza complications in patients with influenza infection.

Review article: prognostic significance of body composition abnormalities in patients with cirrhosis

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.

The impact of frailty on the economic evaluation of geriatric surgery: hospital costs and opportunity costs based on meta-analysis

Objectives: We used a systematic review and meta-analysis to analyze the difference in costs between surgery for frail and non-frail elderly patients. The opportunity cost of frailty in geriatric surgery is estimated using the results.Methodology: Two literature reviews were carried out between 2000 and 2019: (1) studies comparing total hospital costs of frail and non-frail surgical patients; (2) studies evaluating the length of hospital stay and cost for surgical geriatric patients. We performed a meta-analysis of the items selected in the first review. We subsequently calculated the opportunity cost of frail patients, based on the design of a cost/time variable.Results: Twelve articles in the first review were selected (272,717 non-frail and 16,461 frail). Fourteen articles were selected from the second review. Frail patients had higher hospital costs than non-frail patients (22,282.541 € and 16,388.844, p < .001) and a longer hospital stay (10.16 days and 8.4 (p < .001)). The estimated opportunity cost in frail patients is 1,019.56 € (cost/time unit factor of 579.30 €/day).Conclusions: Frail surgical geriatric patients generate a higher total hospital cost, and an opportunity cost arising from not operating in the best possible state of health. Preoperatively treating the frailty of elderly patients will improve the use of health resources.

A Sex-Stratified Prognostic Nomogram Incorporating Body Compositions for Long-Term Mortality in Cirrhosis

BACKGROUND

Alterations in body compositions are related to poor outcomes and the presence of complications in cirrhosis. However, no predictive tools combining all these anthropometric parameters are applicable in the clinical setting. We aimed to clarify the potential utility of body compositions and develop a nomogram incorporating any independent factor for prognosticating long-term mortality in cirrhosis.

METHODS

A total of 414 patients were randomized into primary (n = 274) and validation (n = 140) cohorts. X-tile was performed to identify optimal cut points for stratifying participants. Multivariate Cox regression was performed, and nomogram incorporating body compositions were generated. The utility of developed models was evaluated by Harrell concordance index (C-index), calibration curve, and decision curve analysis (DCA).

RESULTS

Stratifying by X-tilederived cut points, low skeletal muscle index (myopenia), high intramuscular adipose tissue content (myosteatosis), and the ratio of high visceral to subcutaneous adipose tissue area (adiposity) was independently associated with 3-year mortality. A sex-stratified nomogram incorporating anthropometric indices and clinical factors resulted in moderate discriminative accuracy, with a C-index of 0.787 (95% CI, 0.736-0.838) and 0.789 (95% CI, 0.727-0.851) in males and females, respectively. The calibration curve showed predictive survival corresponding optimally with the actual outcomes. Our models were feasible in the clinical settings based on DCA. Similar results were observed in the validation cohort. Additionally, participants could be classified into 3 distinct risk groups by the nomogram.

CONCLUSIONS

Our proposed nomogram embedding body compositions rendered an individualized predictive tool for long-term mortality in cirrhosis.

Skeletal muscle loss phenotype in cirrhosis: A nationwide analysis of hospitalized patients

BACKGROUND & AIMS

There are very limited data on the healthcare burden of muscle loss, the most frequent complication in hospitalized cirrhotics. We determined the healthcare impact of a muscle loss phenotype in hospitalized cirrhotics.

METHODS

The Nationwide Inpatient Sample (NIS) database (years 2010-2014) was analyzed. Search terms included cirrhosis and its complications, and an expanded definition of a muscle loss phenotype that included all conditions associated with muscle loss. In-hospital mortality, length of stay (LOS), post-discharge disposition, co-morbidities and cost during admission were analyzed. Univariate and multivariate analyses were performed to identify associations between a muscle loss phenotype and outcomes. Impact of muscle loss in cirrhotics was compared to that in a random sample (2%) of general medical inpatients.

RESULTS

A total of 162,694 hospitalizations for cirrhosis were reported, of which 18,261 (11.2%) included secondary diagnosis codes for a muscle loss phenotype. A diagnosis of muscle loss was associated with a significantly (p < 0.001 for all) higher mortality (19.3% vs 8.2%), LOS (14.2 ± 15.8 vs. 4.6 ± 6.9 days), and median hospital charge per admission ($21,400 vs. $8573) and a lower likelihood of discharge to home (30.1% vs. 60.2%). All evaluated outcomes were more severe in cirrhotics than general medical patients (n = 534,687). Multivariate regression analysis showed that a diagnosis of muscle loss independently increased mortality by 130%, LOS by 80% and direct cost of care by 119% (p < 0.001 for all). Alcohol use, female gender, malignancies and other organ dysfunction were independently associated with muscle loss.

CONCLUSIONS

Muscle loss contributed to higher mortality, LOS, and direct healthcare costs in hospitalized cirrhotics.

Assessment and significance of sarcopenia in liver transplantation

Sarcopenia frequently occurs in cirrhotic patients who are waiting for liver transplantation (LT). This disease is associated with increased morbidity and mortality rates during the LT period. Recently, the careful assessment of nutritional status for end-stage liver disease patients has received a great deal of attention; hence, numerous methods of evaluating sarcopenia have been proposed. However, most of the methods have limitations, including a lack of objectivity, reproducibility, and ability to discriminate prognoses. In addition, many reports suggest that sarcopenia be used as an adjustment factor for the selection criteria of LT and that sarcopenia be incorporated into the selection criteria for living donor LT in our center. In this article, based on a literature review, we aim to identify the current definition of sarcopenia, the available methods of measurement, the potential novel interventions for the treatment of malnutrition and the significance of sarcopenia in LT.

Clinical relevance of skeletal muscle abnormalities in patients with cirrhosis

Recent advances in body composition evaluation have demonstrated abnormalities in skeletal muscle in patients with cirrhosis. Sarcopenia (severe muscle depletion) and myosteatosis (pathological fat accumulation in muscle) are prevalent muscle abnormalities in patients with cirrhosis that confer poor prognosis. Sarcopenia has become a well-defined factor for adverse clinical outcomes pre- and post-liver transplantation and emerging evidence has suggested the prognostic significance of myosteatosis in predicting mortality and overt hepatic encephalopathy in patients with cirrhosis. Advances in the understating of these muscle abnormalities might help improve therapeutic interventions to correct them and potentially improve outcomes of patients with cirrhosis. Moreover, inclusion of these muscle abnormalities within the current organ allocation policies might lead to a better mortality risk assessment in patients awaiting liver transplant and even to a decrease in the rates of futile liver transplants. This review summarizes the current knowledge regarding the modalities to evaluate skeletal muscle abnormalities in cirrhosis, the incidence and clinical impact of these abnormalities in cirrhosis; existing and potential novel therapeutic strategies are also discussed.

Frailty, Sarcopenia, and Malnutrition in Cirrhotic Patients

Sarcopenia, frailty, and malnutrition are prevalent complications in patients with end-stage liver disease (ESLD) and are associated with increased risk of morbidity and mortality. It is valuable to measure nutritional status, sarcopenia, and frailty over time in order to create interventions tailored to individuals with ESLD. Evaluating sarcopenia and frailty in patients with ESLD is challenging. Further work is needed to perfect these assessments so that clinicians can incorporate these assessments into their decision-making and management plans for cirrhotic patients.

A North American Expert Opinion Statement on Sarcopenia in Liver Transplantation

Loss of muscle mass and function, or sarcopenia, is a common feature of cirrhosis and contributes significantly to morbidity and mortality in this population. Sarcopenia is a main indicator of adverse outcomes in this population, including poor quality of life, hepatic decompensation, mortality in patients with cirrhosis evaluated for liver transplantation (LT), longer hospital and intensive care unit stay, higher incidence of infection following LT, and higher overall health care cost. Although it is clear that muscle mass is an important predictor of LT outcomes, many questions remain, including the best modality for assessing muscle mass, the optimal cut-off values for sarcopenia, the ideal timing and frequency of muscle mass assessment, and how to best incorporate the concept of sarcopenia into clinical decision making. For these reasons, we assembled a group of experts to form the North American Working Group on Sarcopenia in Liver Transplantation to use evidence from the medical literature to address these outstanding questions regarding sarcopenia in LT. We believe sarcopenia assessment should be considered in all patients with cirrhosis evaluated for liver transplantation. Skeletal muscle index (SMI) assessed by computed tomography constitutes the best-studied technique for assessing sarcopenia in patients with cirrhosis. Cut-off values for sarcopenia, defined as SMI < 50 cm² /m² in male and < 39 cm² /m² in female patients, constitute the validated definition for sarcopenia in patients with cirrhosis. Conclusion: The management of sarcopenia requires a multipronged approach including nutrition, exercise, and additional pharmacological therapy as deemed necessary. Future studies should evaluate whether recovery of sarcopenia with nutritional management in combination with an exercise program is sustainable as well as how improvement in muscle mass might be associated with improvement in clinical outcomes.

Sarcopenia in Chronic Liver Disease: Impact on Outcomes

Malnutrition is a common complication in patients with end-stage liver disease (ESLD) awaiting liver transplantation (LT). Malnutrition and sarcopenia overlap in etiology and outcomes, with sarcopenia being defined as reduced skeletal muscle mass and muscle function. The purpose of this review was to identify the prevalence of sarcopenia with and without obesity in adults and children with ESLD and to assess the methodological considerations in sarcopenia diagnosis and the association of sarcopenia with pre- and post-LT outcomes. A total of 38 articles (35 adult and 3 pediatric articles) retrieved from PubMed or Web of Science databases were included. In adults, the prevalence rates of pre-LT sarcopenia, pre-LT sarcopenic obesity (SO), post-LT sarcopenia, and post-LT SO were 14%-78%, 2%-42%, 30%-100%, and 88%, respectively. Only 2 adult studies assessed muscle function in patients diagnosed with sarcopenia. The presence of pre-LT sarcopenia is associated with higher wait-list mortality, greater postoperative mortality, higher infection risk and postoperative complications, longer intensive care unit (ICU) stay, and ventilator dependency. The emerging pediatric data suggest that sarcopenia is prevalent in pre- and post-LT periods. In 1 pediatric study, sarcopenia was associated with poor growth, longer perioperative length of stay (total/ICU) and ventilator dependency, and increased rehospitalization in children after LT. In conclusion, there is a high prevalence of sarcopenia in adults and children with ESLD. Sarcopenia is associated with adverse clinical outcomes. The present review is limited by heterogeneity in the definition of sarcopenia and in the methodological approaches in assessing sarcopenia. Future studies are needed to standardize the sarcopenia diagnosis and muscle function assessment, particularly in the pediatric population, to enable early identification and treatment of sarcopenia in adults and children with ESLD.

Management of the critically ill liver failure patient: surpassing our limitations to reach transplantation

PURPOSE OF REVIEW

Patients with liver failure and liver-related diseases are often critically ill. Here, we review advances in donor organ management, tools for patient selection and highlight ICU management of liver transplant (LT) recipients. A focused discussion on the impact each of these factors have on critical care management of liver failure patients is presented.

RECENT FINDINGS

Artificial liver assist devices to increase donor organ utilization are broadening the potential for transplantation of critically ill patients. Additionally, prognostication tools continue to improve and identify patients salvageable with transplantation despite severely deranged physiology. Most importantly, early recognition of liver failure combined with proactive critical care management reduces the incidence of failure-to-rescue and increases the likelihood of transplantation.

SUMMARY

Liver transplantation is often the only hope for cure, and despite the presence of profound physiologic disturbances surgery remains the goal. In this review, we cover topics key in ICU management of LT recipients. A focused discussion on development of artificial liver assist devices to increase donor organs, prognostic scoring systems to define appropriate transplant recipients, critical care management of liver failure physiology, and bridging modalities and supportive measures are presented.

Sarcopenia in Liver Transplantation

PURPOSE OF REVIEW

Sarcopenia is highly prevalent in end-stage liver disease (ESLD) patients and has been linked to poor outcomes on the wait list and post-transplantation. This current perspectives article reviews the ongoing challenges to define sarcopenia in ESLD patients, describes associations of sarcopenia with wait-list and post-transplantation outcomes, and provides summarized data on efforts to prevent and treat sarcopenia through novel interventions.

RECENT FINDINGS

Supervised exercise programs improve muscle strength, but muscle mass outcomes are limited by short study follow-up times. Branched chain amino acid supplementation may ameliorate sarcopenia in ESLD patients, but studies limited by low participant numbers and confounding. Myostatin inhibition shown to improve sarcopenia in elderly, frail patients; further study needed in ESLD patients. Correction of low testosterone improves sarcopenia in male ESLD patients.

SUMMARY

Recent literature supports sarcopenia as an independent risk factor for poor outcomes in ESLD patients. Ongoing study is limited by poor standardization of sarcopenia definition and relevant muscle-mass cutoffs. Supervised exercise programs should be encouraged for all ESLD patients. More advanced therapies require further clinical investigation before their widespread use.

Sarcopenia in cirrhosis: from pathogenesis to interventions

Sarcopenia (severe muscle depletion) is a prevalent muscle abnormality in patients with cirrhosis that confers poor prognosis both pre- and post-liver transplantation. The pathogenesis of sarcopenia is multifactorial and results from an imbalance between protein synthesis and breakdown. Nutritional, metabolic, and biochemical abnormalities seen in chronic liver disease alter whole body protein homeostasis. Hyperammonemia, increased autophagy, proteasomal activity, lower protein synthesis, and impaired mitochondrial function play an important role in muscle depletion in cirrhosis. Factors including cellular energy status, availability of metabolic substrates (e.g., branched-chain amino acids), alterations in the endocrine system (insulin resistance, circulating levels of insulin, insulin-like growth factor-1, corticosteroids, and testosterone), cytokines, myostatin, and exercise are involved in regulating muscle mass. A favored atrophy of type II fast-twitch glycolytic fibers seems to occur in patients with cirrhosis and sarcopenia. Identification of muscle biological abnormalities and underlying mechanisms is required to plan clinical trials to reverse sarcopenia through modulation of specific mechanisms. Accordingly, a combination of nutritional, physical, and pharmacological interventions might be necessary to reverse sarcopenia in cirrhosis. Moderate exercise should be combined with appropriate energy and protein intake, in accordance with clinical guidelines. Interventions with branched chain amino acids, testosterone, carnitine, or ammonia-lowering therapies should be considered individually. Various factors such as dose, type, duration of supplementations, etiology of cirrhosis, amount of dietary protein intake, and compliance with supplementation and exercise should be the focus of future large randomized controlled trials investigating both prevention and treatment of sarcopenia in this patient population.

Exercise in cirrhosis: Translating evidence and experience to practice

Physical inactivity, sarcopenia, and frailty are highly prevalent, independent predictors of morbidity and mortality in patients with cirrhosis. Across a range of chronic diseases, exercise training is a key recommendation supported by guidelines and, for some conditions, even by governmental funding of exercise programmes. Consistent with the broader chronic disease literature, the evidence for a benefit of exercise in cirrhosis is promising. Several small trials have reported significant improvements in muscle health (mass, strength, functional capacity), quality of life, fatigue, and reductions in the hepatic venous pressure gradient, without adverse events. With strong emerging evidence surrounding the substantial risks of sarcopenia/frailty and our first-hand experiences with liver pre-transplant exercise programmes, we contend that routine patient care in cirrhosis should include an exercise prescription. Some clinicians may lack the resources and necessary background to translate the existing evidence into a practicable intervention. Our team, comprised of physiotherapists, exercise physiologists, hepatologists, transplant specialists, and knowledge translation experts from six North American centres, has distilled the essential background information, tools, and practices into a set of information ready for immediate implementation into clinics ranging from a family practice setting to specialty cirrhosis clinics. Augmenting the rationale and evidence are supplementary materials including video and downloadable materials for both patients and the physician. Supporting the exercising patient is a section regarding information about nutrition, providing practical tips suitable for all patients with cirrhosis.

Increased hospital costs are associated with low skeletal muscle mass in patients undergoing elective open aortic surgery

OBJECTIVE

Low psoas muscle area is shown to be an indicator for worse postoperative outcome in patients undergoing vascular surgical. Additionally, it has been associated with longer durations of hospital stay in patients with cancer who undergo surgery and subsequently greater health care costs in Europe and the United States. We sought to evaluate this effect on hospital expenditure for patients undergoing vascular repair in a health care system with universal access.

METHODS

Skeletal muscle mass was assessed on preoperative abdominal computed tomography scans of patients undergoing open aortic aneurysm repair in a retrospective fashion. The skeletal muscle index (SMI) was used to define low muscle mass. Health care costs were obtained for all patients and the relationship between a low SMI and higher costs was explored using linear regression and cross-sectional analysis.

RESULTS

We included 156 patients (81.5% male) with a median age of 72 years undergoing elective surgery for infrarenal abdominal aortic aneurysm in this analysis. The median SMI for patients with low skeletal muscle mass was 53.21 cm²/kg and for patients without, 70.07 cm²/kg. Hospital duration of stay was 2 days longer in patients with low skeletal muscle mass as compared with patients with normal (14 days vs 11 days; P = .001), as was duration of intensive care stay (3 days vs 1 day; P = .01). The median overall hospital costs were €10,460 higher for patients with a low SMI as compared with patients with a normal physical constitution (€53,739 [interquartile range, €45,007-€62,471] vs €43,279 [interquartile range, €39,509-€47,049]; P = .001). After confounder adjustment, a low SMI was associated with a 14.68% cost increase in overall hospital costs, for a cost increase of €6521.

CONCLUSIONS

Low skeletal muscle mass is independently associated with higher hospital as well as intensive care costs in patients undergoing elective aortic aneurysm repair. Strategies to reduce this risk factor are warranted for these patients.

Financial impact of sarcopenia or low muscle mass - A short review

BACKGROUND & AIMS

Low muscle mass is associated with increased falls, medical complications, length of hospital stay and loss of independence. An increasing number of studies has also shown the association between sarcopenia and health care expenditure. The following narrative review summarizes the current evidence on the economic relevance of low muscle mass (MM) or sarcopenia.

METHODS

An extensive search of the literature in Medline identified twelve studies in English, which evaluated direct and indirect health care expenditure in patients with low muscle mass or sarcopenia (low MM and strength or mobility).

RESULTS

Three studies analysed the cost of age-related loss of MM or strength in large surveys of the general, older population. Six retrospective analyses evaluated perioperative medical costs related to low MM in primarily older patients from different medical areas. One prospective study presented hospital costs related to sarcopenia in patients with gastric cancer. Two studies presented data from general hospital patients. Despite the difference in diagnostic criteria, study population and statistical design, low MM and sarcopenia were consistently identified as predictors of increased health care expenditure in community, perioperative and general hospital settings.

CONCLUSIONS

Low MM and sarcopenia are prevalent and associated with significantly higher health care costs. Considering the demographic change, which will lead to an increasing number of patients with sarcopenia, every effort should be made to identify and treat patients with sarcopenia. The use of a unified definition and diagnostic criteria would allow a better comparison of data.

Should Sarcopenia Increase Priority for Transplant or Is It a Contraindication?

PURPOSE OF REVIEW

The purpose of this review is to discuss the current evidence regarding the impact of sarcopenia on patients with cirrhosis awaiting liver transplantation and to determine if its presence should be considered a criterion for expedited transplantation or a contraindication for transplantation.

RECENT FINDINGS

Sarcopenia is a negative predictor of survival in patients on a waiting list and after liver transplant. The gut-liver axis and the liver-muscle axis have been explored to understand the complex pathophysiology of sarcopenia. Sarcopenia is a frequent finding in patients with cirrhosis. The diagnosis is ideally based on cross-sectional image analysis (CT or MRI) and treatment consists of optimization of caloric and protein intake. To date, prioritizing tools for liver transplantation have not included nutrition or sarcopenia parameters. Patients with a low Model for End-Stage Liver Disease (MELD) or MELD-Na score and sarcopenia would benefit from prioritization for transplant in order to reduce time on waiting list and therefore mortality.