Relationship Between Sarcopenia and Both Physical Activity and Lifestyle in Patients With Chronic Liver Disease

Identifying Risk Factors for Presarcopenia in Early Middle Age

OBJECTIVE

This study aimed to determine whether risk factors for presarcopenia can be identified in a sample of early middle-aged men and women.

DESIGN

Prospective study.

SETTING

Longitudinal data from the Dunedin Multidisciplinary Health and Development Study were used to investigate the relationship between presarcopenia at age 45 years and selected early markers at ages 26, 32, and 38 years.

PARTICIPANTS

Longitudinal data from N=899 participants from the Dunedin Multidisciplinary Health and Development Study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Presarcopenia was defined as low relative appendicular lean mass index assessed by dual energy x-ray absorptiometry and low strength assessed by grip strength. Logistic regressions were used to describe the association between selected markers and presarcopenia at age 45 years.

RESULTS

Multivariate logistic regression revealed that a higher body mass index (BMI) at ages 26, 32, and 38 years was associated with lower likelihood of presarcopenia at age 45 years in both men and women (odds ratio [OR] range, 0.46-0.64). Higher age-normative grip strength at age 38 years in both men and women (OR range, 0.88-0.92) was also associated with lower likelihood for presarcopenia. Lastly, lower self-perceived physical fitness level in men at age 38 years was associated with an increased likelihood of presarcopenia at age 45 years (OR, 9.35; 95% confidence interval, 3.28-26.70).

CONCLUSIONS

BMI and strength were associated with lower likelihood of presarcopenia during middle age. A higher likelihood of presarcopenia was associated with sex-specific lower self-perceived physical fitness. These modifiable biomarkers may serve as targets for clinical screening and early intervention aimed at slowing or preventing progression to sarcopenia in old age.

Association of physical behaviours with sarcopenia in older adults: a systematic review and meta-analysis of observational studies

BACKGROUND

Physical behaviours (ie, physical activity and sedentary behaviour) might have a role in the development of sarcopenia, although the evidence is unclear. We aimed to explore the association of total and intensity-specific levels of physical activity and sedentary behaviour with sarcopenia and its components (ie, muscle mass, muscle strength, and physical performance) in older adults.

METHODS

We conducted a systematic review and meta-analysis and searched MEDLINE (via PubMed), Scopus, and Web of Science from inception to July 26, 2022, for peer-reviewed, observational studies or baseline data from randomised clinical trials conducted in older adults (ie, individual age ≥60 years or mean age ≥65 years) and published in English that reported on the association of physical activity or sedentary behaviour or both with sarcopenia (or its determinants: muscle mass or strength, and physical performance). Physical activity and sedentary behaviour were measured by any method. The main outcome was sarcopenia, which could be diagnosed by any means. Estimates were extracted and pooled using Bayesian meta-analytic models and publication bias was assessed using the Egger's test. This study is registered with PROSPERO, CRD42022315865.

FINDINGS

We identified 15 766 records, of which 124 studies (230 174 older adults; 121 301 [52·7%] were female and 108 873 [47·3%] were male) were included in the systematic review. 86 studies were subsequently included in the meta-analysis. Higher levels of total physical activity were inversely associated with sarcopenia both cross-sectionally (21 studies, n=59 572; odds ratio 0·49, 95% credible interval 0·37-0·62) and longitudinally (four studies, n=7545; 0·51, 0·27-0·94). A protective association was also identified for moderate-to-vigorous physical activity in cross-sectional research (five studies, n=6787; 0·85, 0·71-0·99), whereas no association was identified for the remaining physical behaviours (ie, steps, light physical activity, or sedentary behaviour).

INTERPRETATION

Total and moderate-to-vigorous physical activity are inversely associated with sarcopenia. These findings might support the importance of moderate-to-vigorous, rather than light, intensity physical activity-based interventions to prevent sarcopenia.

FUNDING

None.

TRANSLATION

For the Spanish translation of the abstract see Supplementary Materials section.

Prolonged preoperative sedentary time is a risk factor for postoperative ileus in patients with colorectal cancer: a propensity score-matched retrospective study

PURPOSE

This study aimed to investigate the association between prolonged preoperative sedentary time (ST) and postoperative ileus (POI) after adjusting for confounders in patients with colorectal cancer (CRC).

METHODS

This single-center retrospective study enrolled 155 consecutive patients who underwent surgery for primary CRC. A diagnosis of POI was made by the surgeons if the Clavien-Dindo classification (CD) grade is ≥ 2 within 30 days after surgery. Preoperative ST was assessed using the International Physical Activity Questionnaire usual week short version (Japanese version). Patients were classified into two groups (ST < 6 h/day and ST ≥ 6 h/day) based on results from the questionnaire, and data were analyzed using a propensity score-matching strategy to adjust for confounders. In addition, receiver operating characteristic (ROC) curve analysis was performed to identify the optimal cutoff value of preoperative ST for predicting POI.

RESULTS

Of the 155 patients, 134 were included in the analysis. POI occurred in 16 (11.9%) patients of overall patients and 11 (12.5%) of the 88 matched patients. The logistic regression analysis after propensity score-matching showed that prolonged preoperative ST (ST ≥ 6 h/day) was associated with POI (odds ratio 5.40 (95% confidence interval: 1.09 - 26.60), p = 0.038). The ROC curve analysis indicated that the optimal cutoff value of preoperative ST for predicting POI was 6 h/day.

CONCLUSION

Prolonged preoperative ST is a risk factor for POI in patients with CRC. Therefore, reducing preoperative ST may play an important role in preventing POI.

The association between sedentary behaviour and sarcopenia in older adults: a systematic review and meta-analysis

BACKGROUND

Sedentary behaviour is considered to contribute to sarcopenia when combined with physical inactivity. Whether sedentary behaviour is independently associated with sarcopenia remains controversial. The aim of this study is to explore the association between sedentary behaviour and sarcopenia in older adults in community and long-term care facility settings.

METHODS

Eight electronic databases including MEDLINE, PsycINFO, Wanfang were searched from inception until August 2023. The review included cross-sectional and longitudinal studies concerning the association between sedentary behaviour and sarcopenia among participants over 60 years old. Evidence was pooled by both random-effects meta-analysis and narrative synthesis. Subgroup analyses explored variation according to adjustment of physical activity, settings, and measurements of sedentary behaviour and sarcopenia. Quality assessment for individual studies was performed with the Joanna Briggs Institute (JBI) Critical Appraisal Checklist.

RESULTS

Seventeen articles (16 cross-sectional studies and 1 longitudinal study) of 25,788 participants from community or long-term care facility settings were included. The overall quality of the included studies was rated high. Meta-analysis of 14 cross-sectional studies showed that sedentary behaviour was independently positively associated with sarcopenia: pooled odd ratio 1.36 (95% confidence interval, 1.18-1.58). The independent positive association remained in subgroup analyses by adjustment of physical activity, settings, and measurements of sedentary behaviour and sarcopenia. The narrative analysis corroborated the findings of the meta-analysis and provided additional evidence suggesting that interruptions in sedentary periods were linked to a decreased likelihood of developing sarcopenia.

CONCLUSIONS

The findings support the hypothesis that sedentary behaviour is independently positively associated with sarcopenia in older adults, providing vital indications for the development of strategies to prevent sarcopenia.

SYSTEMATIC REVIEW REGISTRATION

The systematic review protocol has been registered with the PROSPERO database (CRD42022311399).

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.

Association between lean muscle mass and treatment-resistant late-life depression in the IRL-GRey randomized controlled trial

OBJECTIVE

To investigate the relationship between lean muscle mass and treatment response in treatment-resistant late-life depression (TR-LLD). We hypothesized that lower lean muscle mass would be associated with older age, higher physical comorbidities, higher depressive symptom severity, and poorer treatment response.

DESIGN

Secondary analysis of a randomized, placebo-controlled trial.

SETTING

Three academic hospitals in the United States and Canada.

PARTICIPANTS

Adults aged 60+ years with major depressive disorder who did not remit following open treatment with venlafaxine extended-release (XR) (n = 178).

MEASUREMENTS

We estimated lean muscle mass using dual-energy X-ray absorptiometry (DEXA) scans prior to and following randomized treatment with aripiprazole or placebo added to venlafaxine XR. Multivariate regressions estimated influence of demographic and clinical factors on baseline lean muscle mass, and whether baseline lean muscle mass was associated with treatment response, adjusted for treatment arm.

RESULTS

Low lean muscle mass was present in 22 (12.4%) participants. Older age and female sex, but not depressive symptom severity, were independently associated with lower lean muscle mass at baseline. Marital status, baseline depressive symptom severity, and treatment group were associated with improvement of depressive symptoms in the randomized treatment phase. Baseline lean muscle mass was not associated with improvement, regardless of treatment group.

CONCLUSION

As expected, older age and female sex were associated with lower lean muscle mass in TR-LLD. However, contrary to prior results in LLD, lean muscle mass was not associated with depression severity or outcome. This suggests that aripiprazole augmentation may be useful for TR-LLD, even in the presence of anomalous body composition.clinicaltrials.gov Identifier: NCT00892047.

The Effect of Ex Vivo Human Serum from Liver Disease Patients on Cellular Protein Synthesis and Growth

Sarcopenia is a common complication affecting liver disease patients, yet the underlying mechanisms remain unclear. We aimed to elucidate the cellular mechanisms that drive sarcopenia progression using an in vitro model of liver disease. C2C12 myotubes were serum and amino acid starved for 1-h and subsequently conditioned with fasted ex vivo serum from four non-cirrhotic non-alcoholic fatty liver disease patients (NAFLD), four decompensated end-stage liver disease patients (ESLD) and four age-matched healthy controls (CON) for 4- or 24-h. After 4-h C2C12 myotubes were treated with an anabolic stimulus (5 mM leucine) for 30-min. Myotube diameter was reduced following treatment with serum from ESLD compared with CON (−45%) and NAFLD (−35%; p < 0.001 for both). A reduction in maximal mitochondrial respiration (24% and 29%, respectively), coupling efficiency (~12%) and mitophagy (~13%) was identified in myotubes conditioned with NAFLD and ESLD serum compared with CON (p < 0.05 for both). Myostatin (43%, p = 0.04) and MuRF-1 (41%, p = 0.03) protein content was elevated in myotubes treated with ESLD serum compared with CON. Here we highlight a novel, experimental platform to further probe changes in circulating markers associated with liver disease that may drive sarcopenia and develop targeted therapeutic interventions.

Absence of risk of sarcopenia protects cancer patients from fatigue

BACKGROUND

Cancer and its treatments often lead to sarcopenia and fatigue. However, whether these factors are associated remains unproven.

OBJECTIVE

To evaluate whether the risk of sarcopenia predicts the presence of fatigue.

METHODS

A cross-sectional study was completed and included 198 cancer patients of both sexes, undergoing in- and outpatient treatment. The Strength, Assistance for walking, Rise from a chair, Climb stairs, and Falls (SARC-F) and the Functional Assessment of Cancer Therapy Fatigue (FACT-F) were used to assess the risk of sarcopenia and the presence of fatigue, respectively. The cut-off values used to identify the risk of sarcopenia and the severity of fatigue scale were SARC-F ≥ 4 and Fatigue <34, respectively. Logistic regression analysis was performed to evaluate the association between SARC-F and the FACT-F.

RESULTS

Out of 198 patients, 35% were at risk of sarcopenia and of these 87% had fatigue. Patients at risk of sarcopenia had lower scores in the FACT-F subscales, lower handgrip strength, lower performance status, were mostly hospitalized and were sedentary. Logistic regression analysis revealed that patients with SARC-F < 4 had a lower risk of fatigue in both models, crude (OR: 0.83; CI 95% [0.79-0.88], p < 0.0001) as well as adjusted for age, gender, BMI, physical activity, current use of alcoholic beverages, smoking, performance status, cancer type, clinical setting and use of supplements (OR: 0.87; CI 95% [0.81-0.92], p < 0.0001).

CONCLUSION

In patients with cancer, 35% presented risk of sarcopenia and of these 87% had fatigue. In addition, the absence of sarcopenia was considered protective against fatigue.

Associations between homocysteine, inflammatory cytokines and sarcopenia in Chinese older adults with type 2 diabetes

Background

Sarcopenia, an age-related disease, has been implicated as both a cause and consequence of type 2 diabetes mellitus (T2DM) and a symbol of poor prognosis in older adults with T2DM. Therefore, early detection and effective treatment of sarcopenia are particularly important in older adults with T2DM. We aimed to investigate the prevalence of sarcopenia in Chinese older T2DM patients and explore whether homocysteine and inflammatory indexes could serve as biomarkers and participate in the development process of sarcopenia.

Methods

T2DM patients aged over 60 years were consecutively recruited from the ward of department of Endocrinology, Xuanwu Hospital between April 2017 and April 2019. Sarcopenia was defined based on the standard of the Asian Working Group of Sarcopenia, including muscle mass, grip strength and gait speed. Logistic regression was used to explore the association between biochemical indicators and sarcopenia. Receiver operating characteristic (ROC) curves were applied to determine the diagnostic effect of these clinical indicators.

Results

Totally 582 older adults with T2DM were characterized and analyzed in the study. Approximately 8.9% of the older T2DM patients had sarcopenia. After adjusting for age, sex, body mass index (BMI) and hemoglobin A1c (HbA1c), increased concentrations of homocysteine [odds ratio (OR): 2.829; 95% confidence interval (CI), 1.064–7.525] and high-sensitive C-reactive protein (hs-CRP) (OR: 1.021; 95% CI, 1.001–1.042) were independent predictors of sarcopenia; but not interleukin-6. The combination of age, sex, BMI and HbA1c provided a discriminatory effect of sarcopenia with an area under the curve (AUC) of 0.856, when homocysteine was added to the model, the value of the ROC curve was further improved, with an AUC of 0.861.

Conclusion

In the current study, we demonstrated a positive correlation of homocysteine, hs-CRP with sarcopenia in older adults with T2DM and the relationship remained significant even after adjustment for HbA1c. These biomarkers (homocysteine and hs-CRP) may play important roles in the pathological process of sarcopenia.

Dynapenia Rather Than Sarcopenia Is Associated with Metabolic Syndrome in Patients with Chronic Liver Diseases

We aimed to examine the association between sarcopenia-related factors and metabolic syndrome (Met-S) in patients with chronic liver diseases (CLDs, n = 582, average age = 59.5 years, 290 males, 168 liver cirrhosis cases). Met-S was determined based on the Japanese criteria. Sarcopenia was determined based on grip strength (GS) and skeletal muscle index (SMI) by bioelectrical impedance analysis. Our cohort was divided into the four groups: (A) sarcopenia (n = 44), (B) dynapenia (n = 45), (C) presarcopenia (n = 112), and (D) the control (n = 381). Impacts of GS and SMI on Met-S were investigated. In males, waist circumference (WC) ≥ 85 cm was observed in 199 patients (68.6%), while in females, WC ≥ 90 cm was observed in 94 patients (32.2%). Met-S was identified in 109 patients (18.7%). The proportion of Met-S in the group A, B, C and D were 18.2%, 48.9%, 8.0%, and 18.4% (A vs. B, p = 0.0033; B vs. C, p < 0.0001; C vs. D, p = 0.0081; A vs. C, p = 0.0867; A vs. D, p = 1.000, B vs. D, p < 0.0001; overall p value < 0.0001). Multivariate analysis revealed that age, gender, and group B (dynapenia) were significant factors linked to the presence of Met-S. In conclusion, dynapenia rather than sarcopenia is associated with Met-S in CLD patients.

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.

Patient-reported outcomes in patients with non-alcoholic fatty liver disease: A narrative review of Chronic Liver Disease Questionnaire-non-alcoholic fatty liver disease/non-alcoholic steatohepatitis

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease worldwide and one of the leading causes of hepatocellular carcinoma and liver transplantation. Moreover, patients with NAFLD frequently complain of non-specific symptoms including fatigue, abdominal discomfort, as well as anxiety, and NAFLD is reported to affect patient-reported outcomes (PROs). Thus, for clarifying the total burden of NAFLD, it is crucial to assess all associated outcomes, including not only clinical and economic outcomes but also PROs. PROs are thought to reflect what is happening in one's daily life and is an important way patients and health-care professionals communicate. There are various instruments for the assessment of PROs. Recently, a NAFLD/non-alcoholic steatohepatitis (NASH)-specific instrument called "Chronic Liver Disease Questionnaire (CLDQ)-NAFLD/NASH" has been developed. CLDQ-NAFLD/NASH comprises six domains: (i) abdominal symptoms, (ii) activity/energy, (iii) emotional health, (iv) fatigue, (v) systemic symptoms, and (vi) worry. CLDQ-NAFLD/NASH has demonstrated excellent internal consistency, face validity, content validity, and test-retest reliability. It has been sufficiently validated in two international phase 3 clinical trials. In this review, we summarize features of various instruments for assessing PROs by focusing on CLDQ-NAFLD/NASH. We also examine the validity of CLDQ-NAFLD/NASH in Japanese patients and alterations in CLDQ-NAFLD/NASH score in Japanese patients with significant hepatic fibrosis. Moreover, we discuss the utility of CLDQ-NAFLD/NASH in phase 3 clinical trials and in a real-world clinical setting.

Preoperative Sedentary Time Predicts Postoperative Complications in Gastrointestinal Cancer

Background:

Gastrointestinal cancer has a high global prevalence. Postoperative complications (PCs) affect the length of hospital stay and long-term outcomes. However, it is unclear whether preoperative sedentary time is associated with PCs, independently of physical activity (PA). We aimed to investigate the association between preoperative sedentary time and PCs independently of PA in patients who underwent surgery for gastrointestinal cancer.

Methods:

In this prospective study, we included 112 patients who underwent colorectal cancer or gastric cancer surgery. Patient characteristics and surgery-related variables were collected. The Japanese version of the International Physical Activity Questionnaire (the usual 7-day short version) was used to assess preoperative PA and sedentary time. Patients were classified into two groups according to the grade of PCs: Clavien-Dindo (CD) grade <2 and ≥2. Multivariate logistic regression analysis was performed to identify the risk factors for CD grade ≥2 PCs. Receiver operating characteristic curve analysis was used to determine the optimal cutoff point of sedentary time for predicting PCs with CD grade ≥2.

Results:

PCs occurred in 38 patients (33.9%). Sedentary time (odds ratio [OR] 1.29, 95% confidence interval [CI]: 1.09-1.53; p<0.01) and body mass index (OR 1.17, 95% CI: 1.01-1.36; p=0.03) were associated with PCs independently of total PA. The optimal cutoff point of sedentary time for predicting PCs was 6 h/day (sensitivity 0.662, specificity 0.658).

Conclusion:

Preoperative sedentary time is a predictor of PCs in patients who undergo gastrointestinal cancer surgery.

Association between Sarcopenia and Physical Function among Preoperative Lung Cancer Patients

We aimed to investigate the prevalence of sarcopenia using new diagnostic criteria and association of sarcopenia with cardiopulmonary function and physical activity (PA) in preoperative lung cancer patients. The data of 614 patients were obtained from the CATCH-LUNG cohort study. Patients were classified into three groups-normal (n = 520), pre-sarcopenia (n = 60, low skeletal muscle mass index only), and sarcopenia (n = 34, low SMI and strength). Cardiopulmonary function was measured using the 6-min walk test (6MWT), and PA was objectively measured using a wearable device. The adjusted odds ratio (aOR) for a <400-m distance in 6MWT was 3.52 (95% confidence interval (CI) 1.34-9.21) and 6.63 (95% CI 2.25-19.60) in the pre-sarcopenia and sarcopenia groups, respectively, compared to that in the normal group. The aOR (95% CI) for <5000 steps/day was 1.64 (0.65-4.16) and 4.20 (1.55-11.38) in the pre-sarcopenia and sarcopenia groups, respectively, compared to that in the normal group. In conclusion, the prevalence of pre-sarcopenia and sarcopenia was 9.8% and 5.5%, respectively, among preoperative lung cancer patients. Cardiopulmonary function and physical activity were significantly lower in the pre-sarcopenia and sarcopenia groups than in the normal group. Patients with sarcopenia had more robust findings, suggesting the importance of muscle strength and mass.

Low Serum Branched-Chain Amino Acid and Insulin-Like Growth Factor-1 Levels Are Associated with Sarcopenia and Slow Gait Speed in Patients with Liver Cirrhosis

Branched-chain amino acid (BCAA) and insulin-like growth factor 1 (IGF-1) are essential for muscle protein synthesis. We investigated the association of serum BCAA and IGF-1 levels with sarcopenia and gait speed in 192 patients with liver cirrhosis (LC). Sarcopenia was diagnosed according to the Japan Society of Hepatology criteria. Slow gait speed was defined as <1.0 m/s. Subjects were divided into three groups based on baseline BCAA or IGF-1 levels: low (L), intermediate (I), and high (H) groups. The L-BCAA group had the highest prevalence of sarcopenia (60.4%, p < 0.001) and slow gait speed (56.3%, p = 0.008), whereas the H-BCAA group had the lowest prevalence of sarcopenia (8.5%, p < 0.001). The L-IGF-1 group showed the highest prevalence of sarcopenia (46.9%, p < 0.001), whereas the H-IGF-1 group had the lowest prevalence of sarcopenia (10.0%, p < 0.001) and slow gait speed (18.0%, p = 0.003). Using the optimal BCAA and IGF-1 cutoff values for predicting sarcopenia (372 μmol/L and 48.5 ng/mL, respectively), the sensitivity and specificity were 0.709 and 0.759 for BCAA and 0.636 and 0.715 for IGF-1, respectively. Low serum BCAA and IGF-1 levels were associated with sarcopenia and slow gait speed in patients with LC.

Grip Strength: A Useful Marker for Composite Hepatic Events in Patients with Chronic Liver Diseases

Here we sought to clarify the prognostic impact of sarcopenia-related markers (grip strength (GS), muscle mass using bioimpedance analysis and patient quality of life as assessed by the 36-Item Short-Form Health Survey (SF36)) in patients with chronic liver diseases (CLDs, n = 411; 160 liver cirrhosis patients; median age, 64 years) on the incidence of composite hepatic events (CHEs). A GS decrease was defined as <26 kg in men and <18 kg in women, while a skeletal muscle mass index (SMI) decrease was defined as <7.0 kg/m² in men and <5.7 kg/m² in women based on the current guidelines. The physical and metal component summary scores on the SF36 were also included into the analysis. Sixty-two patients (15.1%) had the first incidence of CHEs. The three-year cumulative incidence rates of CHEs in patients with GS decrease or non-decrease were 24.51% and 12.44% (p = 0.0057). The three-year cumulative incidence rates of CHEs in patients with an SMI decrease or non-decrease were 19.65% and 12.99% (p = 0.0982). Multivariate analysis revealed that GS decrease (p = 0.0350) and prothrombin time (p = 0.0293) were significantly associated with the incidence of CHEs. In conclusion, GS can be an independent predictor for CHE development in patients with CLDs.

Review article: malnutrition/sarcopenia and frailty in patients with cirrhosis

BACKGROUND

Malnutrition/sarcopenia and frailty are common in patients with cirrhosis and are associated with poor outcomes.

AIM

To provide an overview of data on the importance, assessment and management of malnutrition/sarcopenia and frailty in cirrhosis.

METHODS

A literature search was conducted in PubMed and other sources, using the search terms "sarcopenia," "muscle," "malnutrition," "cirrhosis," "liver" and "frailty" from inception to April 2019, to identify the relevant studies and international guidelines.

RESULTS

The prevalence of malnutrition/sarcopenia in cirrhosis is 23%-60%. Frailty generally overlaps with malnutrition/sarcopenia in cirrhosis, leading to increased morbidity and mortality. Rapid nutritional screening assessment should be performed in all patients with cirrhosis, and more specific tests for sarcopenia should be performed in those at high risk. The pathogenesis of malnutrition/sarcopenia in cirrhosis is complex/multifactorial and not just reduction in protein/calorie intake. Hyperammonemia appears to be the main driver of sarcopenia in cirrhosis through several molecular signalling pathways. Nutritional management in malnourished patients with cirrhosis should be undertaken by a multidisciplinary team to achieve adequate protein/calorie intake. While the role of branched-chained amino acids remains somewhat contentious in achieving a global benefit of decreasing mortality- and liver-related events, they, and vitamin supplements, are recommended for those with advanced liver disease. Novel strategies to reverse sarcopenia such as hormone supplementation, long-term ammonia-lowering agents and myostatin antagonists, are currently under investigation.

CONCLUSIONS

Malnutrition/sarcopenia and frailty are unique, inter-related and multi-dimensional problems in cirrhosis which require special attention, prompt assessment and appropriate management as they significantly impact morbidity and mortality.

Comparative assessment of sarcopenia using the JSH, AWGS, and EWGSOP2 criteria and the relationship between sarcopenia, osteoporosis, and osteosarcopenia in patients with liver cirrhosis

BACKGROUND

Sarcopenia and osteoporosis reduce life quality and worsen prognosis in patients with liver cirrhosis (LC). When these two complications coexist, a diagnosis of osteosarcopenia is made. We aimed to investigate the actual situations of sarcopenia, osteoporosis, osteosarcopenia, and vertebral fracture, and to clarify the relationship among these events in patients with LC.

METHODS

We describe a cross-sectional study of 142 patients with LC. Sarcopenia was defined according to the Japan Society of Hepatology (JSH) criteria, Asian Working Group for Sarcopenia (AWGS) criteria, and European Working Group on Sarcopenia in Older People (EWGSOP2) criteria. The skeletal muscle mass index (SMI) and handgrip strength were assessed using bioelectrical impedance analysis and a digital grip strength dynamometer, respectively. Bone mineral density (BMD) was measured using dual energy X-ray absorptiometry, and vertebral fracture was evaluated using spinal lateral X-rays. The severity of LC was assessed using the Child-Pugh classification.

RESULTS

Among the 142 patients, the prevalence of sarcopenia was 33.8% (48/142) according to the JSH and AWGS criteria and 28.2% (40/142) according to the EWGSOP2 criteria. The number of patients with osteoporosis, osteosarcopenia, and vertebral fracture was 49 (34.5%), 31 (21.8%), and 41 (28.9%), respectively. Multivariate analysis revealed a close association between sarcopenia and osteoporosis. Osteoporosis was independently associated with sarcopenia [odds ratio (OR) = 3.923, P = 0.010]. Conversely, sarcopenia was independently associated with osteoporosis (OR = 5.722, P < 0.001). Vertebral fracture occurred most frequently in patients with osteosarcopenia (19/31; 61.3%) and least frequently in those without both sarcopenia and osteoporosis (12/76; 15.8%). The SMI and handgrip strength values were significantly correlated with the BMD of the lumbar spine (r = 0.55 and 0.51, respectively; P < 0.001 for both), femoral neck, (r = 0.67 and 0.62, respectively; P < 0.001 for both), and total hip (r = 0.67 and 0.61, respectively; P < 0.001 for both).

CONCLUSIONS

Sarcopenia, osteoporosis, osteosarcopenia, and vertebral fracture were highly prevalent and closely associated with one another in patients with LC. Specifically, patients with osteosarcopenia had the highest risk of vertebral fractures. Early diagnosis of these complications is essential for treatment intervention.

Association between Sarcopenia and Depression in Patients with Chronic Liver Diseases

Association between sarcopenia, as evaluated by grip strength (GS) and skeletal muscle mass (SMM), and depression, as evaluated by Beck Depression Inventory-2nd edition (BDI-II) in chronic liver diseases (CLDs, n = 414, average age = 61.5 years), was investigated. Study subjects were classified into four groups: Group A (n = 60), lower GS and lower SMM (sarcopenia); group B (n = 44), lower GS and higher SMM; group C (n = 100), higher GS and lower SMM; group D (n = 210), higher GS and higher SMM. Factors associated with BDI-II score ≥11 were examined. BDI-II score 0–10 (normal) was found in 284 (68.6%), 11–16 (minimal) in 76 (18.4%), 17–20 (mild) in 24 (5.8%), 21–30 (moderate) in 15 (3.6%), and ≥31 (severe) in 15 (3.6%). The average ± standard deviation BDI-II score in liver cirrhosis (LC) patients (10.2 ± 9.6, n = 152) was significantly higher than that in non-LC patients (7.4 ± 7.2, n = 262) (p = 0.0058). Univariate analysis identified three factors to be significantly associated with BDI-I score ≥11: Our classification (groups of A, B, C, and D) (p = 0.0259), serum albumin (p = 0.0445), and the presence of LC (p = 0.0157). Multivariate analysis revealed that only group A (p = 0.0074, group D as a reference) was significant. In conclusion, sarcopenia can be an independent predictor for depression in CLDs.