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Saueressig C, Alves BC, Luft VC, Anastácio LR, Santos BC, Ferreira LG, Fonseca ALF, Jesus RPD, Oliveira LPMD, Boulhosa RSDSB, Lyra AC, Romeiro FG, Waitzberg DL, Belarmino G, Dall'Alba V. Mid-arm muscle circumference cutoff points in patients with cirrhosis: Low muscle mass related to malnutrition predicts mortality. Nutrition 2024; 125:112471. [PMID: 38797043 DOI: 10.1016/j.nut.2024.112471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 04/06/2024] [Accepted: 04/19/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVES Muscle loss is one of the phenotypic criteria of malnutrition, is highly prevalent in patients with cirrhosis, and is associated with adverse outcomes. Mid-arm muscle circumference (MAMC) estimates the skeletal muscle mass and is especially helpful in cases of fluid overload. This study aimed to propose MAMC cutoff points for patients with cirrhosis and demonstrate its association with 1-year mortality. METHODS This is an analysis of cohort databases from five reference centers in Brazil that included inpatients and outpatients with cirrhosis aged ≥18 y. The nutritional variables obtained were the MAMC (n = 1075) and the subjective global assessment (n = 629). We established the MAMC cutoff points stratified by sex based on the subjective global assessment as a reference standard for malnutrition diagnosis, considering the sensitivity, specificity, and Youden index. An adjusted Cox regression model was used to test the association of MAMC cutoff points and 1-year mortality. RESULTS We included 1075 patients with cirrhosis, with a mean age of 54.8 ± 11.3 y; 70.4% (n = 757) male. Most patients had alcoholic cirrhosis (47.1%, n = 506) and were classified as Child-Pugh B (44.7%, n = 480). The MAMC cutoff points for moderate and severe depletion were ≤21.5 cm and ≤24.2 cm; ≤20.9 cm and ≤22.9 cm for women and men, respectively. According to these cutoff points, 13.8% (n = 148) and 35.1% (n = 377) of the patients had moderate or severe MAMC depletion, respectively. The 1-year mortality rate was 17.3% (n = 186). In the multivariate analysis adjusted for sex, age, MELD-Na, and Child-Pugh scores, a severe depletion in MAMC was an independent increased risk factor for 1-year mortality (HR: 1.71, 95% CI: 1.24-2.35, P < 0.001). Each increase of 1 cm in MAMC values was associated with an 11% reduction in 1-year mortality risk (HR: 0.89, 95% CI: 0.85-0.94, P < 0.001). CONCLUSIONS Low MAMC classified according to the new cutoff points predicts mortality risk in patients with cirrhosis and could be used in clinical practice.
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Affiliation(s)
- Camila Saueressig
- Faculty of Medicine, Graduate Program in Gastroenterology and Hepatology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
| | - Bruna Cherubini Alves
- Faculty of Medicine, Graduate Program in Gastroenterology and Hepatology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Vivian Cristine Luft
- Faculty of Medicine, Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Bárbara Chaves Santos
- Food Science Graduate Program, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Lívia Garcia Ferreira
- Nutrition and Health Graduate Program, Universidade Federal de Lavras, Lavras, Brazil
| | | | - Rosângela Passos de Jesus
- Department of Science Nutrition, Universidade Federal da Bahia, Salvador, Brazil; Food, Nutrition, and Health Graduate Program, Universidade Federal da Bahia, Salvador, Brazil
| | - Lucivalda Pereira Magalhães de Oliveira
- Department of Science Nutrition, Universidade Federal da Bahia, Salvador, Brazil; Food, Nutrition, and Health Graduate Program, Universidade Federal da Bahia, Salvador, Brazil
| | | | - André Castro Lyra
- Department of Gastroenterology, Universidade Federal da Bahia, Salvador, Brazil
| | - Fernando Gomes Romeiro
- Gastroenterology Division, Department of Internal Medicine, Universidade Estadual Paulista, São Paulo, Brazil
| | - Dan Linetzky Waitzberg
- Faculty of Medicine, Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
| | - Giliane Belarmino
- Faculty of Medicine, Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
| | - Valesca Dall'Alba
- Faculty of Medicine, Graduate Program in Gastroenterology and Hepatology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Nutrition Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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2
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Kim JH. Machine-learning classifier models for predicting sarcopenia in the elderly based on physical factors. Geriatr Gerontol Int 2024; 24:595-602. [PMID: 38744528 DOI: 10.1111/ggi.14895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 03/25/2024] [Accepted: 05/02/2024] [Indexed: 05/16/2024]
Abstract
AIM As the size of the elderly population gradually increases, musculoskeletal disorders, such as sarcopenia, are increasing. Diagnostic techniques such as X-rays, computed tomography, and magnetic resonance imaging are used to predict and diagnose sarcopenia, and methods using machine learning are gradually increasing. This study aimed to create a model that can predict sarcopenia using physical characteristics and activity-related variables without medical diagnostic equipment, such as imaging equipment, for the elderly aged 60 years or older. METHODS A sarcopenia prediction model was constructed using public data obtained from the Korea National Health and Nutrition Examination Survey. Models were built using Logistic Regression, Support Vector Machine (SVM), XGBoost, LightGBM, RandomForest, and Multi-layer Perceptron Neural Network (MLP) algorithms, and the feature importance of the models trained with the algorithms, except for SVM and MLP, was analyzed. RESULTS The sarcopenia prediction model built with the LightGBM algorithm achieved the highest test accuracy, of 0.848. In constructing the LightGBM model, physical characteristic variables such as body mass index, weight, and waist circumference showed high importance, and activity-related variables were also used in constructing the model. CONCLUSIONS The sarcopenia prediction model, which consisted of only physical characteristics and activity-related factors, showed excellent performance. This model has the potential to assist in the early detection of sarcopenia in the elderly, especially in communities with limited access to medical resources or facilities. Geriatr Gerontol Int 2024; 24: 595-602.
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Affiliation(s)
- Jun-Hee Kim
- Department of Physical Therapy, College of Software and Digital Healthcare Convergence, Yonsei University, Wonju, South Korea
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3
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Reincke M, Seufert J, Laubner K, Meyer-Steenbuck M, Dammer A, Sturm L, Thimme R, Bettinger D, Schultheiss M. Reduced bone mineral density is associated to post-TIPS survival of female patients with decompensated cirrhosis. Dig Liver Dis 2024:S1590-8658(24)00710-2. [PMID: 38679509 DOI: 10.1016/j.dld.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/10/2024] [Accepted: 04/10/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Malnutrition is common in patients with cirrhosis, eventually leading to sarcopenia and loss of bone mass. AIMS The aims of this study was the assessment of body composition (BC) and bone mineral density (BMD) in patients with decompensated cirrhosis and the prognostic impact on survival after transjugular intrahepatic portosystemic shunt (TIPS) implantation. METHODS BMD and BC of 107 patients with cirrhosis undergoing TIPS implantation were prospectively analyzed by dual-energy X-ray absorptiometry. The prevalence and predisposing risk factors for reduced BMD and sarcopenia were assessed. Impact on 12-month survival after TIPS implantation was evaluated. RESULTS Sarcopenia was diagnosed in 48.6 % of the patients with a predominance of male patients (58.7% vs. 25.0 %, p = 0.001). 67.2 % had reduced BMD. Low BMI was independently associated with sarcopenia (OR 0.751 (95 % CI: 0.662;0.852), p < 0.001) and reduced BMD (OR 0.851 (0.773;0.937), p = 0.001). Patients with reduced BMD, but not sarcopenia, had impaired 12-month survival after TIPS-implantation (61.2% vs. 82.9 %, p = 0.030). Subgroup analysis showed that this was especially valid for female patients. CONCLUSIONS Sarcopenia and reduced BMD are frequently observed in patients with decompensated cirrhosis. Reduced BMD negatively affects post-TIPS survival. Since malnutrition is a leading cause, assessment of nutritional status and specific treatment should be included in clinical practice.
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Affiliation(s)
- Marlene Reincke
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Jochen Seufert
- Department of Medicine II, Division of Endocrinology and Diabetology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Katharina Laubner
- Department of Medicine II, Division of Endocrinology and Diabetology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany
| | - Maximilian Meyer-Steenbuck
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Anna Dammer
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Lukas Sturm
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany
| | - Michael Schultheiss
- Department of Medicine II, Division of Gastroenterology and Hepatology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Germany.
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El Khoueiry C, Slim R, Rida M, Khoury B, Honein K, Smayra T, Yaghi C. New Scanographic Index for the Detection of Frailty in Patients with Cirrhosis with a Prognostic Impact. Middle East J Dig Dis 2024; 16:102-108. [PMID: 39131107 PMCID: PMC11316193 DOI: 10.34172/mejdd.2024.376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 02/22/2024] [Indexed: 08/13/2024] Open
Abstract
Background Frailty is linked to an increased incidence of hepatic decompensation and mortality in cirrhosis. The aim of our study was to identify a novel scanographic score that predicts frailty and its impact in cirrhosis. Methods This study included 51 patients with cirrhosis. We used the frailty scale risk assessment score to identify frail patients. The density and area of different muscles at L3 level were analyzed on computed tomography (CT) sections. The L3 skeletal muscle area adjusted to height and density ratio (L3-SMDHR) was defined as L3 muscle wall*height/density. Results The L3-SMHDR is significantly higher in frail patients and in patients with Child B/C scores. Frailty was correlated with L3-SMHDR. Frailty and L3- SMHDR were correlated with liver-related events (LRE). We set the most appropriate cut-offs of L3-SMHDR for both sensitivity and specificity by using the ROC: 5.4 for males and 4.7 for females. The AUROC score was 0.784 for male and 0.975 for female patients. The Kappa score between frailty and L3-SMHDR was 0.752, with a percentage of agreement of 87.5%, showing a substantial agreement. This ratio with the divided categories has a sensitivity of 100%, a specificity of 76%, a positive predictive value of 79.3% and a negative predictive value of 100%. Patients with high L3-SMHDR have significantly lower survival time and a higher incidence of LRE. Conclusion The L3-SMHDR is a new index for identifying frailty in cirrhosis by using measurable and reproducible variables. It can be used as a prognostic factor for frailty in patients with cirrhosis.
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Affiliation(s)
| | - Rita Slim
- Hotel Dieu de France Hospital, Beirut, Lebanon
| | | | | | | | | | - Cesar Yaghi
- Hotel Dieu de France Hospital, Beirut, Lebanon
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Mendez-Guerrero O, Carranza-Carrasco A, Chi-Cervera LA, Torre A, Navarro-Alvarez N. Optimizing nutrition in hepatic cirrhosis: A comprehensive assessment and care approach. World J Gastroenterol 2024; 30:1313-1328. [PMID: 38596498 PMCID: PMC11000076 DOI: 10.3748/wjg.v30.i10.1313] [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: 11/28/2023] [Revised: 01/23/2024] [Accepted: 02/25/2024] [Indexed: 03/14/2024] Open
Abstract
Cirrhosis is considered a growing cause of morbidity and mortality, which represents a significant public health problem. Currently, there is no effective treatment to reverse cirrhosis. Treatment primarily centers on addressing the underlying liver condition, monitoring, and managing portal hypertension-related complications, and evaluating the potential for liver transplantation in cases of decompensated cirrhosis, marked by rapid progression and the emergence of complications like variceal bleeding, hepatic encephalopathy, ascites, malnutrition, and more. Malnutrition, a prevalent complication across all disease stages, is often underdiagnosed in cirrhosis due to the complexities of nutritional assessment in patients with fluid retention and/or obesity, despite its crucial impact on prognosis. Increasing emphasis has been placed on the collaboration of nutritionists within hepatology and Liver transplant teams to deliver comprehensive care, a practice that has shown to improve outcomes. This review covers appropriate screening and assessment methods for evaluating the nutritional status of this population, diagnostic approaches for malnutrition, and context-specific nutrition treatments. It also discusses evidence-based recommendations for supplementation and physical exercise, both essential elements of the standard care provided to cirrhotic patients.
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Affiliation(s)
- Osvely Mendez-Guerrero
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Anaisa Carranza-Carrasco
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Luis Alberto Chi-Cervera
- Clínica de Especialidades Gastrointestinales y Hepáticas, Hospital Star Medica, Merida 97133, Yucatan, Mexico
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Nalu Navarro-Alvarez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Molecular Biology, Universidad Panamericana School of Medicine, Campus México, Mexico City 03920, Mexico
- Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO 80045, United States
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6
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Haj Ali S, Abu Sneineh A, Hasweh R. Nutritional assessment in patients with liver cirrhosis. World J Hepatol 2022; 14:1694-1703. [PMID: 36185724 PMCID: PMC9521456 DOI: 10.4254/wjh.v14.i9.1694] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/09/2022] [Accepted: 09/09/2022] [Indexed: 02/06/2023] Open
Abstract
Malnutrition is a liver cirrhosis complication affecting more than 20%-50% of patients. Although the term can refer to either nutrient deficiency or excess, it usually relates to undernutrition in cirrhosis settings. Frailty is defined as limited physical function due to muscle weakness, whereas sarcopenia is defined as muscle mass loss and an advanced malnutrition stage. The pathogenesis of malnutrition in liver cirrhosis is multifactorial, including decreased oral intake, maldigestion/malabsorption, physical inactivity, hyperammonemia, hypermetabolism, altered macronutrient metabolism and gut microbiome dysbiosis. Patients with chronic liver disease with a Body Mass Index of < 18.5 kg/m2 and/or decompensated cirrhosis or Child-Pugh class C are at the highest risk of malnutrition. For patients at risk of malnutrition, a detailed nutritional assessment is required, typically including a history and physical examination, laboratory testing, global assessment tools and body composition testing. The latter can be done using anthropometry, cross-sectional imaging including computed tomography or magnetic resonance, bioelectrical impedance analysis and dual-energy X-ray absorptiometry. A multidisciplinary team should screen for and treat malnutrition in patients with cirrhosis. Malnutrition and sarcopenia are associated with an increased risk of complications and a poor prognosis in patients with liver cirrhosis; thus, it is critical to diagnose these conditions early and initiate the appropriate nutritional therapy. In this review, we describe the prevalence and pathogenesis of malnutrition in liver cirrhosis patients and discuss the best diagnostic approach to nutritional assessment for them.
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Affiliation(s)
- Sara Haj Ali
- Department of Internal Medicine, Faculty of Medicine, Al-Balqa Applied University, Salt 19117, Jordan
| | - Awni Abu Sneineh
- Department of Gastroenterology and Hepatology, University of Jordan, Faculty of Medicine, Amman 11942, Jordan
| | - Reem Hasweh
- Department of Internal Medicine, Faculty of Medicine, Al-Balqa Applied University, Salt 19117, Jordan
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Hey P, Hoermann R, Gow P, Hanrahan TP, Testro AG, Apostolov R, Sinclair M. Reduced upper limb lean mass on dual energy X-ray absorptiometry predicts adverse outcomes in male liver transplant recipients. World J Transplant 2022; 12:120-130. [PMID: 35979539 PMCID: PMC9258268 DOI: 10.5500/wjt.v12.i6.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/24/2022] [Accepted: 05/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pre-transplant muscle wasting measured by computed tomography has been associated with adverse clinical outcomes after liver transplantation including increased rates of sepsis and hospitalisation days. Upper limb lean mass (LM) measured by dual-energy X-ray absorptiometry (DEXA) was recently identified as a novel predictor of sarcopenia-associated mortality in men waitlisted for transplantation.
AIM To investigate the use of DEXA LM in predicting gender-stratified early post-transplant outcomes.
METHODS Liver transplant recipients who underwent pre-transplant DEXA body composition imaging between 2002 and 2017 were included. Endpoints included post-transplant mortality and graft failure, bacterial infections, acute cellular rejection (ACR) and intensive care and total hospital length of stay.
RESULTS Four hundred and sixty-nine patients met inclusion criteria of which 338 were male (72%). Median age was 55.0 years (interquartile range 47.4, 59.7) and model for end-stage liver disease (MELD) score 16. Median time from assessment to transplantation was 7 mo (3.5, 12). Upper limb LM was inversely associated with bacterial infections at 180 d post-transplant (hazard ratio = 0.42; 95% confidence interval: 0.20-0.89; P = 0.024) in males only. There was a negative correlation between upper limb LM and intensive care (τb = -0.090, P = 0.015) and total hospital length of stay (τb = -0.10, P = 0.0078) in men. In women, neither MELD nor body composition parameters were associated with post-transplant adverse outcomes or increased length of stay. Body composition parameters, MELD and age were not associated with 90-d mortality or graft failure in either gender. There were no significant predictors of early ACR.
CONCLUSION Sarcopenia is an independent and potentially modifiable predictor of increased post-transplant bacterial infections and hospital length of stay in men with cirrhosis. DEXA upper limb LM provides a novel measure of muscle wasting that has prognostic value in this cohort. The lack of association in women requires further investigation.
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Affiliation(s)
- Penelope Hey
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
- Department of Medicine, University of Melbourne, Melbourne 3052, Australia
| | - Rudolf Hoermann
- Department of Medicine, University of Melbourne, Melbourne 3052, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
- Department of Medicine, University of Melbourne, Melbourne 3052, Australia
| | | | - Adam G Testro
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
- Department of Medicine, University of Melbourne, Melbourne 3052, Australia
| | - Ross Apostolov
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
- Department of Medicine, University of Melbourne, Melbourne 3052, Australia
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
- Department of Medicine, University of Melbourne, Melbourne 3052, Australia
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Heymsfield SB, Prado CM, Cristina Gonzalez M, Cederholm T, Jensen GL, Barazzoni R, Compher C. Author Response to LTE JPEN-2022-04-138. Reply to: Evans WJ. Lean body mass should not be used as a surrogate measurement of muscle mass in malnourished men and women: Comment on Compher et al. JPEN J Parenter Enteral Nutr. 2022 Apr 19. doi: 10.1002/jpen.2384. Epub ahead of print. PMID: 35437790. JPEN J Parenter Enteral Nutr 2022; 46:1500-1501. [PMID: 35633304 DOI: 10.1002/jpen.2414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 11/05/2022]
Abstract
Professor Evans comments (1) on our recent Global Leadership Initiative on Malnutrition (GLIM) Guidance published in the journal (2). In the title of his letter, Dr. Evans uses the term "lean body mass", an archaic body component description long abandoned by experts in the field. We believe this term is being used to refer to fat-free mass, the now accepted terminology for the component derived as the difference between body weight and fat mass This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Steven B Heymsfield
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Carla M Prado
- Human Nutrition Research Unit, Department of Agricultural, Food & Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - M Cristina Gonzalez
- Post-Graduate Program in Health and Behavior, Catholic University of Pelotas, Pelotas, Rio Grande do Sul, Brazil
| | - Tommy Cederholm
- Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, and Theme Aging, Karolinska University Hospital, Stockholm, Sweden
| | - Gordon L Jensen
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Rocco Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Charlene Compher
- Department of Biobehavioral Health Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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Lai JC, Tandon P, Bernal W, Tapper EB, Ekong U, Dasarathy S, Carey EJ. Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 74:1611-1644. [PMID: 34233031 PMCID: PMC9134787 DOI: 10.1002/hep.32049] [Citation(s) in RCA: 268] [Impact Index Per Article: 89.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Jennifer C Lai
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Puneeta Tandon
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Albert, Canada
| | - William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Elliot B Tapper
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI
| | - Udeme Ekong
- Georgetown University School of Medicine, Medstar Georgetown Transplant Institute, Washington, DC
| | - Srinivasan Dasarathy
- Department of Gastroenterology and Hepatology, Inflammation and Immunity, Lerner Research Institute, Cleveland Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic in Arizona, Phoenix, AZ
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10
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Williams FR, Milliken D, Lai JC, Armstrong MJ. Assessment of the Frail Patient With End-Stage Liver Disease: A Practical Overview of Sarcopenia, Physical Function, and Disability. Hepatol Commun 2021; 5:923-937. [PMID: 34141980 PMCID: PMC8183168 DOI: 10.1002/hep4.1688] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/14/2020] [Accepted: 01/24/2021] [Indexed: 12/22/2022] Open
Abstract
Frailty has emerged as a powerful predictor of clinical outcomes (e.g., decompensation, hospitalization, mortality) in patients with end-stage liver disease (ESLD). It is therefore of paramount importance that all patients with ESLD undergo an assessment of frailty, to support life and death decision making (i.e., candidacy for critical care, transplantation) and aid with prioritization of evolving prehabilitation services (i.e., nutrition, physiotherapy, psychotherapy). This article aims to provide a practical overview of the recent advances in the clinical, radiological, and remote assessment tools of the frail patient with ESLD. Historically, clinicians have incorporated an assessment of frailty using the "end-of-the-bed test" or "eyeball test" into their clinical decision making. However, over the last decade, numerous nonspecific and specific tools have emerged. The current evidence supports the use of a combination of simple, user-friendly, objective measures to first identify frailty in ESLD (notably Clinical Frailty Scale, Liver Frailty Index), followed by a combination of serial tools to assess specifically sarcopenia (i.e., muscle ultrasound), physical function (i.e., chair stands, hand grip strength), functional capacity (i.e., 6-minute walk test), and physical disability (i.e., activities of daily living).
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Affiliation(s)
- Felicity R Williams
- National Institute for Health Research Biomedical Research CenterInstitute of Inflammation and AgeingUniversity of BirminghamBirminghamUnited Kingdom.,Liver Transplant UnitQueen Elizabeth University Hospital BirminghamBirminghamUnited Kingdom
| | - Don Milliken
- Department of AnesthesiologyUniversity of CaliforniaSan FranciscoCAUSA
| | - Jennifer C Lai
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Matthew J Armstrong
- Liver Transplant UnitQueen Elizabeth University Hospital BirminghamBirminghamUnited Kingdom.,National Institute for Health Research Biomedical Research CenterCenter for Liver ResearchUniversity of BirminghamBirminghamUnited Kingdom
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11
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Eriksen CS, Kimer N, Suetta C, Møller S. Arm lean mass determined by dual-energy X-ray absorptiometry is superior to characterize skeletal muscle and predict sarcopenia-related mortality in cirrhosis. Am J Physiol Gastrointest Liver Physiol 2021; 320:G729-G740. [PMID: 33729006 DOI: 10.1152/ajpgi.00478.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Sarcopenia worsens survival in patients with advanced liver disease including cirrhosis. In this study, we aimed to characterize skeletal muscle status by dual-energy X-ray absorptiometry (DXA) in patients with cirrhosis and examine the association between different skeletal muscle compartments and mortality. We included 231 men and 84 women (Child A, B, and C) with cirrhosis and 315 healthy matched controls (231 men and 84 women). Body composition was assessed with DXA. Appendicular skeletal muscle index (ASMI), arms index (AI), and legs index (LI) were calculated by normalizing lean mass to height squared. Low ASMI was defined as ASMI < 7.0 kg/m2 in men and <5.5 kg/m2 in women. Biochemical and hemodynamic data were recorded for cirrhotic patients and mortality data retrieved from registers. Low ASMI was more prevalent in both men (49%) and women (43%) with cirrhosis compared with healthy men (8%) and women (5%) (P < 0.001). ASMI and LI were lowest in Child B, whereas AI decreased gradually with advancing Child class. ASMI was inversely associated with mortality in men [HR = 0.74 (0.59-0.93), P < 0.01], and this was mainly driven by AI [HR = 0.37 (0.18-0.71), P < 0.01]. AI showed closer association than ASMI or LI to both the severity of liver disease and to mortality, which may be due to increasing prevalence of leg edema with disease progression in this population. Determination of arm lean mass may add information on survival in patients with cirrhosis.NEW & NOTEWORTHY Sarcopenia increases mortality in patients with end-stage liver disease. We show that arm lean mass determined by dual-energy X-ray absorptiometry is a better marker than the traditional appendicular skeletal muscle mass when predicting sarcopenia-related mortality in patients with cirrhosis of different severity. The findings add to the dispute about the optimal method for repeated assessments of skeletal muscle status in patients with cirrhosis and may have implications for clinical decision making.
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Affiliation(s)
- Christian Skou Eriksen
- Center of Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, Hvidovre University Hospital, Copenhagen, Denmark
| | - Nina Kimer
- Gastro Unit, Medical Division, Hvidovre University Hospital, Copenhagen, Denmark
| | - Charlotte Suetta
- Geriatric Research Unit, Department of Geriatrics and Palliative Medicine, Bispebjerg and Frederiksberg University Hospitals, Copenhagen, Denmark.,Geriatric Research Unit, Department of Medicine, Herlev and Gentofte University Hospitals, Copenhagen, Denmark.,Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Søren Møller
- Center of Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, Hvidovre University Hospital, Copenhagen, Denmark
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12
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Son SW, Song DS, Chang UI, Yang JM. Definition of Sarcopenia in Chronic Liver Disease. Life (Basel) 2021; 11:349. [PMID: 33923561 PMCID: PMC8074027 DOI: 10.3390/life11040349] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 02/07/2023] Open
Abstract
Sarcopenia, which is characterized by decline in muscle mass, muscle strength, and physical performance, is common in patients with chronic liver disease (CLD) and is associated with poor clinical outcomes. Several consensus definitions for community-dwelling elderly people have been proposed, and these recommend the use of various tools and tests to assess muscle properties and performance. These measurement tools have also been applied in patients with CLD and have been useful for predicting prognosis. However, sarcopenia and its diagnostic criteria specific to patients with CLD have not yet been clearly defined. In addition, fluid retention and body composition should be considered when sarcopenia is assessed in patients with CLD. This review aims to introduce definitions of sarcopenia and diagnostic tools used in patients with CLD.
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Affiliation(s)
| | - Do Seon Song
- Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.W.S.); (U.I.C.); (J.M.Y.)
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13
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Lee CM, Kang BK, Kim M. Radiologic Definition of Sarcopenia in Chronic Liver Disease. Life (Basel) 2021; 11:86. [PMID: 33504046 PMCID: PMC7910987 DOI: 10.3390/life11020086] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/18/2021] [Accepted: 01/21/2021] [Indexed: 12/14/2022] Open
Abstract
Sarcopenia is prevalent in patients with chronic liver disease, and affected patients tend to have worse clinical outcomes and higher mortality. However, relevant analyses are limited by heterogeneity in the definition of sarcopenia and in the methodological approaches in assessing it. We reviewed several radiologic methods for sarcopenia in patients with chronic liver disease. Dual energy X-ray absorptiometry (DXA) can measure muscle mass, but it is difficult to evaluate muscle quality using this technique. Computed tomography, known as the gold standard for diagnosing sarcopenia, enables the objective measurement of muscle quantity and quality. The third lumbar skeletal muscle index (L3 SMI) more accurately predicted the mortality of subjects than the psoas muscle index (PMI). Few studies have evaluated the sarcopenia of chronic liver disease using ultrasonography and magnetic resonance imaging, and more studies are needed. Unification of the measurement method and cut-off value would facilitate a more systematic and universal prognosis evaluation in patients with chronic liver disease.
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Affiliation(s)
| | | | - Mimi Kim
- Department of Radiology, College of Medicine, Hanyang University, Seoul 04763, Korea; (C.-m.L.); (B.K.K.)
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14
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Radiologic Definition of Sarcopenia in Chronic Liver Disease. LIFE (BASEL, SWITZERLAND) 2021. [PMID: 33504046 DOI: 10.3390/life11020086.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Sarcopenia is prevalent in patients with chronic liver disease, and affected patients tend to have worse clinical outcomes and higher mortality. However, relevant analyses are limited by heterogeneity in the definition of sarcopenia and in the methodological approaches in assessing it. We reviewed several radiologic methods for sarcopenia in patients with chronic liver disease. Dual energy X-ray absorptiometry (DXA) can measure muscle mass, but it is difficult to evaluate muscle quality using this technique. Computed tomography, known as the gold standard for diagnosing sarcopenia, enables the objective measurement of muscle quantity and quality. The third lumbar skeletal muscle index (L3 SMI) more accurately predicted the mortality of subjects than the psoas muscle index (PMI). Few studies have evaluated the sarcopenia of chronic liver disease using ultrasonography and magnetic resonance imaging, and more studies are needed. Unification of the measurement method and cut-off value would facilitate a more systematic and universal prognosis evaluation in patients with chronic liver disease.
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15
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Han P, Chen X, Yu X, Zhang Y, Song P, Cai M, Liang L, Liang Z, Yang R, Jin F, Wang L, Guo Q. The Predictive Value of Sarcopenia and Its Individual Criteria for Cardiovascular and All-Cause Mortality in Suburb-dwelling Older Chinese. J Nutr Health Aging 2020; 24:765-771. [PMID: 32744574 DOI: 10.1007/s12603-020-1390-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The aim of the present study is to investigate the associations between the Asian Working Group for Sarcopenia (AWGS) sarcopenic definition, and its individual criteria, and risk of cardiovascular disease (CVD) and all-cause mortality in the Chinese elderly. METHODS Longitudinal analysis of 1,264 participants aged 60 years or older at baseline (2013-2014) living in suburban areas, China. Sarcopenia was defined according to the recommended algorithm of AWGS. Muscle mass was measured by a direct segmental multifrequency bioelectrical impedance analysis. Muscle strength was assessed by handgrip strength, and physical performance measured via usual walking speed. RESULTS Cox proportional hazard models were used to assess the risk of CVD and all-cause mortality. After 40 months of follow-up, forty-eight deaths (4.2%) died in this cohort. The mortality rate with sarcopenia was 4.7% in men and 3.8% in women. After adjusting for potential confounders, the risk of all-cause death was 4.15 times higher in subjects with sarcopenia. Furthermore, low muscle mass (HR: 2.62, 95% CI 1.34-5.13) and low grip strength (HR: 5.79; 95% CI 2.28-14.71), but not walking speed, were found to be significantly associated with all-cause mortality. Risk of CVD mortality was significantly greater in sarcopenia. Low grip strength and low walking speed were associated with 11 times (HR: 11.03, 95% CI 1.58-77.02) and 13 times (HR: 13.02; 95% CI 1.18-143.78) higher risk of CVD mortality. CONCLUSIONS Sarcopenia and components of sarcopenia were associated with greater CVD and all-cause mortality. Pertinent prevention or rehabilitation programs projects should look to promote healthy aging in different types of sarcopenia group.
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Affiliation(s)
- P Han
- Qi Guo, M.D., Ph.D. Department of Rehabilitation Medicine, Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital, 1500 Zhouyuan Road, Pudong New District, Shanghai, 201318, China, Fax: 86-22-8333-6977, E-mail:
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16
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Georgiou A, Papatheodoridis GV, Alexopoulou A, Deutsch M, Vlachogiannakos I, Ioannidou P, Papageorgiou MV, Papadopoulos N, Yannakoulia M, Kontogianni MD. Validation of cutoffs for skeletal muscle mass index based on computed tomography analysis against dual energy X-ray absorptiometry in patients with cirrhosis: the KIRRHOS study. Ann Gastroenterol 2019; 33:80-86. [PMID: 31892802 PMCID: PMC6928470 DOI: 10.20524/aog.2019.0432] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/29/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Accurate assessments of muscle mass in patients with cirrhosis are necessary in clinical practice. Computed tomography (CT) of the upper abdomen has been proposed as a useful method for quantifying muscle mass. Recently, Carey et al developed specific cutoffs for muscle wasting based on the skeletal muscle index at the L3 vertebra (L3-SMI) for cirrhotic patients. The aim of the present study was to assess the concurrent validity of the newly proposed cutoffs of Carey et al, along with others widely used in several clinical contexts, using dual energy X-ray absorptiometry (DXA) as the reference method. Methods: Data were evaluated from 97 Caucasian patients (59.8% male, 59.1±11.6 years old, 45.4% decompensated) with cirrhosis of various etiologies. Muscle mass was assessed using the appendicular lean mass index (ALMI) by DXA and the L3-SMI by CT. Low L3-SMI was defined in relation to 5 different cutoffs. Results: Low muscle mass prevalence was 13.4% according to ALMI and 26.8-45.4% according to the different cutoffs applied for L3-SMI. The Carey et al, Prado et al and Montano-Loza et al cutoffs showed similar sensitivity (all 69.2%) and specificity (79.8%, 76.2% and 75.0%, respectively) and high accuracy (78.4%, 75.3% and 74.2%). The Carey et al cutoffs showed the highest diagnostic validity against DXA the multivariate odds ratio adjusted for age, sex, body mass index category, disease etiology and model for end-stage liver disease score (95% confidence interval) was 5.88 (1.36-25.4), P=0.018. Conclusion: Compared to DXA, the cutoffs for identifying muscle wasting proposed by Carey et al were proven to be the most accurate.
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Affiliation(s)
- Alexandra Georgiou
- Department of Dietetics Nutrition and School of Health Education Sciences and Harokopio University (Georgiou Alexandra Yannakoulia Mary Meropi D. Kontogianni) Gastroenterology
| | - Georgios V Papatheodoridis
- Department of Medical School of National and Kapodistrian Athens University of Laiko General Hospital of Athens (Papatheodoridis Georgios V. Vlachogiannakos Ioannis Ioannidou Panagiota Maria-Vasiliki Papageorgiou)
| | - Alexandra Alexopoulou
- 2nd Department Medicine of Internal Medical School of National and Kapodistrian Athens University of Hippokration General Athens Hospital of Athens Greece (Alexopoulou Alexandra Melanie Deutsch)
| | - Melanie Deutsch
- 2nd Department Medicine of Internal Medical School of National and Kapodistrian Athens University of Hippokration General Athens Hospital of Athens Greece (Alexopoulou Alexandra Melanie Deutsch)
| | - Ioannis Vlachogiannakos
- Department of Medical School of National and Kapodistrian Athens University of Laiko General Hospital of Athens (Papatheodoridis Georgios V. Vlachogiannakos Ioannis Ioannidou Panagiota Maria-Vasiliki Papageorgiou)
| | - Panagiota Ioannidou
- Department of Medical School of National and Kapodistrian Athens University of Laiko General Hospital of Athens (Papatheodoridis Georgios V. Vlachogiannakos Ioannis Ioannidou Panagiota Maria-Vasiliki Papageorgiou)
| | - Maria-Vasiliki Papageorgiou
- Department of Medical School of National and Kapodistrian Athens University of Laiko General Hospital of Athens (Papatheodoridis Georgios V. Vlachogiannakos Ioannis Ioannidou Panagiota Maria-Vasiliki Papageorgiou)
| | - Nikolaos Papadopoulos
- 1st Department Medicine of Internal Army Share Fund Hospital of Athens (Nikolaos Papadopoulos) Athens Greece
| | - Mary Yannakoulia
- Department of Dietetics Nutrition and School of Health Education Sciences and Harokopio University (Georgiou Alexandra Yannakoulia Mary Meropi D. Kontogianni) Gastroenterology
| | - Meropi D Kontogianni
- Department of Dietetics Nutrition and School of Health Education Sciences and Harokopio University (Georgiou Alexandra Yannakoulia Mary Meropi D. Kontogianni) Gastroenterology
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17
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Santos LAA, Lima TB, Ietsugu MDV, Nunes HRDC, Qi X, Romeiro FG. Anthropometric measures associated with sarcopenia in outpatients with liver cirrhosis. Nutr Diet 2019; 76:613-619. [PMID: 30869199 DOI: 10.1111/1747-0080.12523] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/30/2019] [Accepted: 02/06/2019] [Indexed: 02/05/2023]
Abstract
AIM The present study aimed to identify variables associated with sarcopenia in cirrhotic outpatients using clinical data, anthropometric measures and lab tests. In a single centre prospective study, 261 cirrhotic outpatients were followed on average for 2 years. The diagnostic criteria of sarcopenia were applied according to the current guidelines, combining muscle strength and appendicular muscle mass index. METHODS Age, sex, liver disease aetiology and the Model of End-Stage Liver Disease score were included as independent variables, as well as mid-arm circumference (MAC), body mass index and triceps skinfold. Multiple logistic regression was applied including all independent variables (maximum model). Then, the analysis was performed only with the variables that were significant in the first analysis (parsimonious model). Once the variable most related to sarcopenia was determined by the two models, the area under the receiver operator characteristic curve was calculated. Mortality rates were described for patients with and without sarcopenia. RESULTS Sarcopenia was diagnosed in 14 subjects (5.36%), and the variable best associated with sarcopenia was MAC (P < 0.01). The 1-year mortality rate of 35.71% found among subjects with sarcopenia was not significantly higher (P = 0.07) than the 15.38% observed among those without this condition. CONCLUSIONS Before examinations requiring ionising radiation, patients with cirrhosis can be submitted to simple screening tools to identify those who have a high risk of sarcopenia, thus promoting a cost-effective assessment.
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Affiliation(s)
- Lívia A A Santos
- Department of Internal Medicine, Botucatu Medical School, Universidade Estadual Paulista (UNESP), São Paulo, Brazil
| | - Talles B Lima
- Department of Internal Medicine, Botucatu Medical School, Universidade Estadual Paulista (UNESP), São Paulo, Brazil
| | - Marjorie do Val Ietsugu
- Department of Internal Medicine, Botucatu Medical School, Universidade Estadual Paulista (UNESP), São Paulo, Brazil
| | - Hélio R de Carvalho Nunes
- Department of Public Health, Botucatu Medical School, Universidade Estadual Paulista (UNESP), São Paulo, Brazil
| | - Xingshun Qi
- General Hospital of Shenyang Military Command, Shenyang, China
| | - Fernando G Romeiro
- Department of Internal Medicine, Botucatu Medical School, Universidade Estadual Paulista (UNESP), São Paulo, Brazil
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18
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Carey EJ, Lai JC, Sonnenday C, Tapper EB, Tandon P, Duarte-Rojo A, Dunn MA, Tsien C, Kallwitz ER, Ng V, Dasarathy S, Kappus M, Bashir MR, Montano-Loza AJ. A North American Expert Opinion Statement on Sarcopenia in Liver Transplantation. Hepatology 2019; 70:1816-1829. [PMID: 31220351 PMCID: PMC6819202 DOI: 10.1002/hep.30828] [Citation(s) in RCA: 149] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/06/2019] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Elizabeth J. Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, CA, USA
| | | | - Elliot B. Tapper
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Puneeta Tandon
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Andres Duarte-Rojo
- Center for Liver Diseases, Thomas E. Starzl Transplantation Institute, and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael A. Dunn
- Center for Liver Diseases, Thomas E. Starzl Transplantation Institute, and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Cynthia Tsien
- Gastroenterology Department, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Vicky Ng
- Transplant and Regenerative Medicine Centre, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Matthew Kappus
- Division of Gastroenterology, Duke University School of Medicine, Durham, NC, USA
| | - Mustafa R. Bashir
- Division of Abdominal Imaging, Duke University Medical Center Durham, NC, USA
| | - Aldo J. Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
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19
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20
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Sinclair M. Controversies in Diagnosing Sarcopenia in Cirrhosis-Moving from Research to Clinical Practice. Nutrients 2019; 11:nu11102454. [PMID: 31615103 PMCID: PMC6836123 DOI: 10.3390/nu11102454] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 10/07/2019] [Accepted: 10/10/2019] [Indexed: 02/07/2023] Open
Abstract
Sarcopenia, defined as loss of muscle mass and function, is increasingly recognized as a common consequence of advanced cirrhosis that is associated with adverse clinical outcomes. Despite the recent proliferation in publications pertaining to sarcopenia in end-stage liver disease, there remains no single 'best method' for its diagnosis. The inability to identify a gold standard is common to other specialties, including geriatrics from which many diagnostic tools are derived. Controversies in diagnosis have implications for the accuracy and reproducibility of cohort studies in the field, largely prohibit the introduction of sarcopenia measurement into routine patient care and impede the development of clinical trials to identify appropriate therapies. Difficulties in diagnosis are partly driven by our ongoing limited understanding of the pathophysiology of sarcopenia in cirrhosis, the mechanisms by which it impacts on patient outcomes, the heterogeneity of patient populations, and the accuracy, availability and cost of assessments of muscle mass and function. This review discusses the currently studied diagnostic methods for sarcopenia in cirrhosis, and outlines why reaching a consensus on sarcopenia diagnosis is important and suggests potential ways to improve diagnostic criteria to allow us to translate sarcopenia research into improvements in clinical care.
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Affiliation(s)
- Marie Sinclair
- Department of Medicine, The University of Melbourne, Parkville 3050, Australia.
- Austin Health, Liver Transplant Unit, 145 Studley Road, Heidelberg 3084, Australia.
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21
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Sinclair M, Chapman B, Hoermann R, Angus PW, Testro A, Scodellaro T, Gow PJ. Handgrip Strength Adds More Prognostic Value to the Model for End-Stage Liver Disease Score Than Imaging-Based Measures of Muscle Mass in Men With Cirrhosis. Liver Transpl 2019; 25:1480-1487. [PMID: 31282126 DOI: 10.1002/lt.25598] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 06/18/2019] [Indexed: 12/13/2022]
Abstract
Sarcopenia is associated with mortality in cirrhosis, but there is no gold standard for its diagnosis. The comparative utility of different diagnostic methods is unknown. This single-center observational cohort study followed 145 men referred for liver transplant evaluation between 2005 and 2012. Muscle mass was estimated by handgrip strength, dual energy X-ray absorptiometry (DEXA) lean mass, and single-slice computed tomography (CT) scan at the fourth lumbar vertebra. Recorded outcomes included time to death or liver transplantation. The median (interquartile range [IQR]) age was 54 years (47-59 years), and Model for End-Stage Liver Disease (MELD) score was 17 (14-23). Of 145 men, 56 died with a median (IQR) time to death of 7.44 months (3.48-14.16 months). In total, 79 men underwent transplantation with median (IQR) time to transplant of 7.20 months (3.96-12.84 months). The prevalence of sarcopenia differed between diagnostic modalities with 70.3% using CT muscle mass, 45.9% using handgrip strength, and 38.7% using DEXA. Muscle mass was inversely associated with wait-list mortality for measured CT muscle mass (hazard ratio [HR], 0.94; 95% confidence interval (CI), 0.90-0.98; P = 0.002), DEXA muscle mass (HR, 0.99; 95% CI, 0.99-0.99; P = 0.003), and handgrip strength (HR, 0.94; 95% CI, 0.91-0.98; P = 0.002). These results retained significance independent of the MELD score. In predicting mortality, the MELD-handgrip strength bivariate Cox model was superior to a MELD-CT muscle Cox model (P < 0.001). In conclusion, handgrip strength combined with MELD score was the superior predictive model in this novel study examining 3 commonly employed techniques to diagnose sarcopenia in cirrhosis. Handgrip strength has additional potential clinical benefits because it can be performed serially without the radiation dose, cost, and access issues attributable to CT and DEXA.
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Affiliation(s)
- Marie Sinclair
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Brooke Chapman
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Rudolf Hoermann
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter W Angus
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Adam Testro
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Thomas Scodellaro
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Paul J Gow
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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22
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Ooi PH, Hager A, Mazurak VC, Dajani K, Bhargava R, Gilmour SM, Mager DR. Sarcopenia in Chronic Liver Disease: Impact on Outcomes. Liver Transpl 2019; 25:1422-1438. [PMID: 31242345 DOI: 10.1002/lt.25591] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/24/2019] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Poh Hwa Ooi
- Department of Agricultural, Food and Nutritional Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Amber Hager
- Department of Agricultural, Food and Nutritional Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Vera C Mazurak
- Department of Agricultural, Food and Nutritional Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Khaled Dajani
- Department of General Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Ravi Bhargava
- Department of Radiology and Diagnostic Imaging, Walter C. Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Susan M Gilmour
- Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Division of Pediatric Gastroenterology and Nutrition/Transplant Services, The Stollery Children's Hospital, Alberta Health Services, Edmonton, Alberta, Canada
| | - Diana R Mager
- Department of Agricultural, Food and Nutritional Sciences, University of Alberta, Edmonton, Alberta, Canada.,Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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23
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Prognostic value of energy expenditure and respiratory quotient measuring in patients with liver cirrhosis. Clin Nutr 2019; 38:1899-1904. [DOI: 10.1016/j.clnu.2018.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/07/2018] [Accepted: 07/01/2018] [Indexed: 12/18/2022]
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Lindqvist C, Brismar TB, Majeed A, Wahlin S. Assessment of muscle mass depletion in chronic liver disease: Dual-energy x-ray absorptiometry compared with computed tomography. Nutrition 2019; 61:93-98. [DOI: 10.1016/j.nut.2018.10.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/18/2018] [Accepted: 10/24/2018] [Indexed: 12/12/2022]
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Chang KV, Chen JD, Wu WT, Huang KC, Han DS. Association of loss of muscle mass with mortality in liver cirrhosis without or before liver transplantation: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e14373. [PMID: 30817561 PMCID: PMC6831322 DOI: 10.1097/md.0000000000014373] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Liver cirrhosis is a risk factor for the loss of muscle mass, which is associated with numerous adverse health outcomes. This meta-analysis aimed to examine whether loss of muscle mass was a predictor of increased mortality in cirrhotic patients without or before liver transplantation. METHODS Without language restriction, PubMed and Embase were searched for articles published from the earliest records to December 2018 investigating the influence of loss of muscle mass on survival of cirrhotic patients. Those who had undergone liver transplantation and had hepatocellular carcinoma were excluded. The main outcome was the hazard ratio (HR) for the association of mortality with loss of muscle mass, and the secondary outcome was the association of loss of muscle mass with Child-Pugh class and death caused by severe infection. RESULTS The meta-analysis included 16 observational studies, comprising 4070 participants. The pooled crude and adjusted HRs for the association of mortality with loss of muscle mass were 2.05 (95% confidence interval [CI], 1.51-2.78) and 2.36 (95% CI, 1.61-3.46). Using Child-Pugh Class A as reference, the odds ratios (ORs) for the association of loss of muscle mass with Child-Pugh Class B and Class C were 1.68 (95% CI, 0.96-2.92) and 1.94 (95% CI, 0.66-5.65). Patients with loss of muscle mass were likely to have infection-related mortality (OR = 3.38, 95% CI, 0.61-18.88) but the association did not reach statistical significance. CONCLUSIONS Loss of muscle mass is associated with mortality in cirrhotic patients without or before liver transplantation. Future studies should be conducted to explore whether exercise and nutritional supplementation can reverse muscle mass loss and improve long-term survival.
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Affiliation(s)
- Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch
- Community and Geriatric Medicine Research Center, National Taiwan University Hospital, Bei-Hu Branch
- Department of Physical Medicine and Rehabilitation, National Taiwan University College of Medicine, Taipei
| | - Jin-De Chen
- Community and Geriatric Medicine Research Center, National Taiwan University Hospital, Bei-Hu Branch
- Department of Gastroenterology, National Taiwan University Hospital, Bei-Hu Branch
| | - Wei-Ting Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch
| | - Kuo-Chin Huang
- Community and Geriatric Medicine Research Center, National Taiwan University Hospital, Bei-Hu Branch
- Department of Family Medicine, National Taiwan University College of Medicine, Taipei
| | - Der-Sheng Han
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch
- Community and Geriatric Medicine Research Center, National Taiwan University Hospital, Bei-Hu Branch
- Department of Physical Medicine and Rehabilitation, National Taiwan University College of Medicine, Taipei
- Health Science and Wellness Center, National Taiwan University, Taipei, Taiwan
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Duarte-Rojo A, Ruiz-Margáin A, Montaño-Loza AJ, Macías-Rodríguez RU, Ferrando A, Kim WR. Exercise and physical activity for patients with end-stage liver disease: Improving functional status and sarcopenia while on the transplant waiting list. Liver Transpl 2018; 24:122-139. [PMID: 29024353 DOI: 10.1002/lt.24958] [Citation(s) in RCA: 127] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 09/05/2017] [Accepted: 09/09/2017] [Indexed: 12/20/2022]
Abstract
Sarcopenia and physical deconditioning are frequent complications in patients with cirrhosis and end-stage liver disease (ESLD). They are the end result of impaired dietary intake, chronic inflammation, altered macronutrient and micronutrient metabolism, and low physical activity. Frailty is the end result of prolonged sarcopenia and physical deconditioning. It severely affects a patient's functional status and presents in approximately 1 in 5 patients on the liver transplantation waiting list. Sarcopenia, poor physical fitness/cardiopulmonary endurance (CPE), and frailty are all associated with increased mortality in ESLD. Clinical trials addressing the usefulness of exercise in patients with cirrhosis have shown that it improves the metabolic syndrome, sarcopenia, CPE, health-related quality of life, and hepatic venous pressure gradient. Although evidence on the benefits of exercise on clinical outcomes derived from large clinical trials is still missing, based on existing literature from multiple medical subspecialties, we believe that an exercise program coupled to a tailored nutritional intervention benefits both cardiopulmonary and musculoskeletal functions, ultimately translating into improved functional status, sense of well-being, and possibly less complications from portal hypertension. In conclusion, although supervised exercise training is the prevailing approach to manage ESLD patients, such intervention is not sustainable or feasible for most patients. Innovative home-based physical activity interventions may be able to effectively reach a larger number of patients. Liver Transplantation 24 122-139 2018 AASLD.
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Affiliation(s)
| | - Astrid Ruiz-Margáin
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán,", Mexico City, Mexico
| | - Aldo J Montaño-Loza
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Canada
| | - Ricardo U Macías-Rodríguez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán,", Mexico City, Mexico
| | - Arny Ferrando
- Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford School of Medicine, Stanford, CA
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