Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases

Skeletal muscle protein turnover responses to parenteral nutrition in patients with alcoholic liver cirrhosis and sarcopenia

Alcoholic liver cirrhosis (ALC) is accompanied by sarcopenia. The aim of this study was to investigate the acute effects of balanced parenteral nutrition (PN) on skeletal muscle protein turnover in ALC. Eight male patients with ALC and seven age- and sex-matched healthy controls were studied for 3 h of fasting followed by 3 h of intravenous PN (SmofKabiven 1,206 mL: amino acid = 38 g, carbohydrates = 85 g, and fat = 34 g) 4 mL/kg/h. We measured leg blood flow and sampled paired femoral arteriovenous concentrations and quadriceps muscle biopsies while providing a primed continuous infusion of [ring-2d5]-phenylalanine to quantify muscle protein synthesis and breakdown. Patients with ALC exhibited shorter 6-min walking distance (ALC: 487 ± 38 vs. controls: 722 ± 14 m, P < 0.05), lower hand-grip strength (ALC: 34 ± 2 vs. controls: 52 ± 2 kg, P < 0.05), and computed tomography (CT)-verified leg muscle loss (ALC: 5,922 ± 246 vs. controls: 8,110 ± 345 mm2, P < 0.05). Net leg muscle phenylalanine uptake changed from negative (muscle loss) during fasting to positive (muscle gain) in response to PN (ALC: -0.18 ± +0.01 vs. 0.24 ± 0.03 µmol/kg muscle·min-1; P < 0.001 and controls: -0.15 ± 0.01 vs. 0.09 ± 0.01 µmol/kg muscle·min-1; P < 0.001) but with higher net muscle phenylalanine uptake in ALC than controls (P < 0.001). Insulin concentrations were substantially higher in patients with ALC during PN. Our results suggest a higher net muscle phenylalanine uptake during a single infusion of PN in stable patients with ALC with sarcopenia compared with healthy controls.NEW & NOTEWORTHY Muscle protein turnover responses to parenteral nutritional (PN) supplementation have not previously been studied in stable alcoholic liver cirrhosis (ALC). We applied stable isotope tracers of amino acids to directly quantify net muscle protein turnover responses to PN in sarcopenic males with ALC and healthy controls. We found a higher net muscle protein gain in ALC during PN, thereby providing the physiological rationale for future clinical trials of PN as a potential countermeasure to sarcopenia.

The Clinical Spectrum and Manifestations of Acute-on-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) is characterized by abrupt decompensation in a patient with chronic liver disease with extrahepatic organ dysfunction and is implicated in an increased risk of mortality. ACLF may be present in approximately 20% to 40% of hospitalized cirrhosis. There are several diagnostic scoring systems for ACLF; one defined by the North American Consortium for Study of End-stage Liver Disease is the presence of acutely decompensated cirrhosis complicated by failure of two or more organ systems: circulatory, renal, neurological, coagulopathy, and/or pulmonary.

Body composition and short-term mortality in patients critically ill with acute-on-chronic liver failure

Background & Aims

Body composition is sex dependent and associated with an increased mortality risk in patients with cirrhosis. We evaluated whether it was also associated with short-term mortality in patients critically ill with acute-on-chronic liver failure (ACLF).

Patients and methods

We retrospectively included all patients with cirrhosis and ACLF hospitalised in the intensive care unit (ICU) of Lausanne University Hospital between 2010 and 2019 for whom an abdominal computed tomography (CT) scan performed ±7 days from admission was available. Patients from the ICU of Paul Brousse University Hospital admitted between 2017 and 2020 served as an external cohort. All body composition parameters at the third lumbar vertebral level (L3) were quantified using a deep learning-based method.

Results

In total, 192 patients from Lausanne were included. Median age was 62 years and 28-day survival rate was 58.2%. In males, variables independently associated with 28-day mortality on days 1 and 3 were Chronic Liver Failure Consortium (CLIF-C) ACLF-lactate and sarcopenia. In females, CLIF-C ACLF-lactate on days 1 and 3 was the only predictor of 28-day survival. We derived two scores combining sarcopenia and the CLIF-C ACLF-lactate score on days 1 and 3, with area under the receiver operating characteristic outperforming the CLIF-C ACLF-lactate score alone in male but not in female patients. Comparable results were found in the external cohort of 58 patients and supported the sex specificity of the performance of the model. Patients with sarcopenia had increased risks of invasive fungal infection and renal replacement therapy.

Conclusion

Sarcopenia was associated with 28-day mortality in male but not in female patients critically ill with ACLF. Although screening for sarcopenia could impact the management of male patients, further studies are needed in female cohorts to investigate whether other body composition parameters are associated with outcomes.

Impact and implications

Body composition, easily assessed by CT, is altered in patients with cirrhosis and associated with outcome; it has never been investigated in patients critically ill with ACLF. The results of the present study, underlining the benefit of sarcopenia evaluation to improve prognosis prediction in males critically ill with ACLF, are of importance for physicians managing such patients to optimise the decision-making process toward continued treatment, liver transplantation, or limitation of care. In a wider sense, besides the number and course of organ failures, the results recall the weight of the general condition of males with ACLF at admission to ICU. In females critically ill with ACLF, in analyses limited by the sample size, none of the body composition parameters was associated with short-term mortality independently of organ failures; this suggests that the number and course of organ failures are the main determinant of mortality in these patients.

Handgrip strength is associated with 12-month survival in male patients suffering with advanced chronic liver disease

BACKGROUND

Advanced chronic liver disease (ACLD) patients are usually malnourished, and both conditions in combination increase the likelihood of unfavourable clinical outcomes. Handgrip strength (HGS) has been suggested as a relevant parameter for nutritional assessment and predictor of adverse clinical outcomes in ACLD. However, the HGS cut-off values for ACLD patients have not yet been reliably established. The aims of this study were to preliminarily identify HGS reference values in a sample population of ACLD male patients and to assess their association with survival over a 12-month follow-up period.

METHODS

This was a prospective observational study with preliminary analysis of outpatients and inpatients. A total of 185 male patients with a medical diagnosis of ACLD met the inclusion criteria and were invited to participate in the study. The physiological variation in muscle strength related to the age of the individuals included in the study was considered to obtain cut-off values.

RESULTS

After categorising HGS by age group (adults: 18-60 years; elderly: ≥60 years), the reference values obtained were 32.5 kg for the adults and 16.5 kg for the elderly. During the 12-month follow-up, 20.5% of the patients died, and 76.3% of those had been identified with reduced HGS.

CONCLUSIONS

Patients with adequate HGS showed significantly higher 12-month survival than those with reduced HGS within the same period. Our findings show that HGS is an important predictive parameter for clinical and nutritional follow-up in ACLD male patients.

Reduced 3-year risk of hospital admission and mortality after 12-week resistance training of cirrhosis patients: A follow-up of a randomized clinical trial

BACKGROUND AND AIM

Physical activity confers health benefits in many diseases but remains almost unstudied for cirrhosis. We investigated whether a period of resistance training affects the subsequent long-term risk of hospitalization or mortality among patients with cirrhosis.

METHODS

The study includes 39 participants with cirrhosis Child-Pugh class A/B who participated in a prior clinical trial randomized to either resistance training three times per week for 12 weeks or a control group. We gathered data through medical records from trial entry and the following 3 years. The outcomes were time to first hospitalization and all-cause mortality. We used regression models to examine the associations between trial groups and outcomes, adjusting for Child-Pugh class, age, gender, and comorbidity.

RESULTS

Nine patients who trained and 15 controls were hospitalized, resulting in a lower risk of first hospitalization in the training group (adjusted subdistribution hazard ratio of 0.40, 95% confidence interval [CI] [0.17, 0.92]; P = 0.03). One patient who trained and six controls died, resulting in a lower all-cause mortality in the training group (adjusted hazard ratio of 0.06, 95% CI [0.01, 0.66]; P = 0.02).

CONCLUSION

Twelve weeks of resistance training was associated with a reduced risk of first hospitalization and mortality among patients with cirrhosis Child-Pugh class A/B 3 years after trial entry. The mechanisms of this effect are not identified, and larger studies are warranted.

Risk Stratification for Sarcopenic Obesity in Subjects With Nonalcoholic Fatty Liver Disease

BACKGROUND & AIMS

The impact of the severity of sarcopenic obesity (SO) in nonalcoholic fatty liver disease (NAFLD) on the risk of significant liver fibrosis or cardiovascular disease (CVD) remains unclear. We aimed to identify high-risk subjects with SO for significant liver fibrosis or CVD among subjects with SO and NAFLD.

METHODS

This multicenter, retrospective study involved 23,889 subjects with NAFLD who underwent a health screening program (2014-2020). Sarcopenia was defined based on gender-specific sarcopenia index cutoff using multi-frequency bioelectric impedance analysis. High-risk subjects with SO were defined as those with significant liver fibrosis by fibrosis-4 index >2.67 or atherosclerotic CVD risk score >20%. Multivariable logistic regression analysis for identifying high-risk subjects with SO was performed in a cross-sectional cohort with SO, and further validation was performed in a longitudinal cohort.

RESULTS

SO prevalence was 5.4% (n = 1297 of 23,889). Older age (unstandardized beta [β] = 3.23; P < .001), male (β = 1.66; P = .027), sarcopenia index (β = -6.25; P = .019), and metabolic syndrome (β = 1.75; P < .001) were significant risk factors for high-risk SO. Based on a high-risk SO screening model, high-risk subjects with SO had significantly higher odds of significant liver fibrosis (training: adjusted odds ratio [aOR], 3.72; validation: aOR, 2.38) or CVD (training: aOR, 5.20; validation: aOR, 3.71) than subjects without SO (all P < .001). In subgroup analyses, the cumulative incidence of significant liver fibrosis or CVD development was significantly higher in high-risk subjects with SO than in low-risk subjects with SO in a longitudinal cohort considering all-cause mortality and liver transplantation as competing risks (sub-distribution hazard ratio, 5.37; P < .001).

CONCLUSION

The high-risk screening model may enable the identification of high-risk subjects with SO with NAFLD.

Detection of Sarcopenia in Patients with Liver Cirrhosis Using the Bioelectrical Impedance Analysis

Bioelectrical impedance analysis (BIA) is a body composition assessment method. We aimed to determine its accuracy in the detection of sarcopenia in patients with liver cirrhosis (LC), using skeletal muscle index (SMI) at the level of third lumbar vertebra (L3-SMI) obtained using multislice computed tomography as the reference method. Patients with LC were enrolled in the period October 2019-March 2022 and follow-ups were conducted until January 2023. Their BIA parameters were compared against L3-SMI, and BIA cut-off values were proposed using AUROC analysis. Patients underwent outcome analysis based on obtained clinical characteristics. A total of 106 patients were included. We found a fair correlation between BIA parameters with the L3-SMI. We determined cut-off values of ≤11.1 kg/m2 for BIA-SMI (Se 73%, Sp 66%, AUROC 0.737, p < 0.001) and ≤5.05° for phase angle (PA) (Se 79%, Sp 60%, AUROC 0.762, p < 0.001) in the detection of sarcopenia. The relative risk of death was 2.2 times higher in patients with skeletal muscle mass (SMM) ≤ 36.5 kg. SMM was significantly associated with outcome in Kaplan-Meier analysis. This non-invasive and simple method that showed fair performances and a very good outcome prediction could provide for the unmet need for fast and affordable detection of sarcopenia in patients with LC and should be further evaluated.

Evaluation of the nutritional status of patients with liver cirrhosis

BACKGROUND

Progressive malnutrition coexists with liver diseases, particularly in patients with cirrhosis. Early diagnosis of malnutrition in patients with advanced stages of chronic liver disease and the implementation of appropriate nutritional treatment for malnourished patients should be an integral part of the therapeutic process.

AIM

To evaluate the nutritional status of patients with various severities of advanced liver fibrosis, using various nutritional status parameters.

METHODS

This study involved 118 patients with liver cirrhosis who were classified into three groups according to their Child-Pugh score. The nutritional status of the patients in each group was assessed using different methods. The average values obtained from the measurements were calculated for each research group. The influence of disease stage on the examined parameters of nutritional status was determined using one-way analysis of variance. To investigate the relationship between the parameters determining nutritional status and the stage of disease advancement, a correlation analysis was performed.

RESULTS

The Child-Pugh A group had the highest mean body weight (76.42 kg), highest mean body mass index (BMI) (26.72 kg/m²), and largest mean arm circumference (27.64 cm). In the Child-Pugh B group, the mean scores of all examined variables were lower than those of the Child-Pugh A group, whereas the mean body weight and BMI of the Child-Pugh C group were higher than those of the Child-Pugh B group. There was a very strong correlation between the Child-Pugh classification and subjective global assessment score; a very strong correlation between the Child-Pugh classification and arm circumference; a strong correlation between the Child-Pugh classification and body weight, albumin concentration, fat-free mass index, muscle mass index, phase angle, and BMI; and an average correlation between Child-Pugh classification and fat mass index. Notably, these indicators deteriorated with disease progression.

CONCLUSION

Advanced liver fibrosis leads to the deterioration of many nutritional status parameters. The extent of malnutrition increases with the progression of liver fibrosis. The Child-Pugh score reflects the nutritional status.

Association between Dietary Habits and Sarcopenia in Patients with Liver Cirrhosis

Sarcopenia and sarcopenic obesity are frequent complications of cirrhosis, and the dietary patterns of patients with these diseases significantly impact the development of both conditions. This study aims to evaluate the adequacy of the dietary intake of patients with liver cirrhosis. A total of 201 patients with liver cirrhosis were included in this analysis. We evaluated the nutritional status of the patients as stated by EWGSOP2 criteria. Subjects were divided into three groups: non-sarcopenic, sarcopenic, and with sarcopenic obesity. We conducted a dietary assessment three times over nonconsecutive 24 h periods within a month. According to EWGSOP2 criteria, combining low handgrip strength with low skeletal muscle index, the prevalence of sarcopenia was 57.2%. Sarcopenic obesity was found in 25.3% of patients. In the sarcopenic group of patients, the energy intake was lower than the current recommendations. Regarding protein intake, the consumption was relatively low in both sarcopenia and sarcopenic obesity samples of patients (0.85 g/kg body weight and 0.77 g/kg BW, p < 0.0001). Patients had a median of 2-3 eating episodes daily, and they often missed late-evening snacks. In conclusion, diet quality in cirrhotic patients was relatively poor, and energy and protein intakes were lower than suggested.

Identifying opportunities for hepatic encephalopathy self-management: A mixed methods systematic review and synthesis

Background

Hepatic encephalopathy (HE) in cirrhosis is an extremely challenging complication for patients and care partners. To identify potentially modifiable factors to enhance HE self-management strategies, we conducted a synthesis of quantitative and qualitative research about real-world HE behaviours, knowledge, and experiences.

Methods

Using the EPPI-Centre's mixed methods synthesis procedure, a systematic literature search in five databases was completed; methods of selected articles underwent critical appraisal followed by descriptive analysis and coded line-by-line of content. Through refutational translation, the findings from the quantitative and qualitative syntheses were juxtaposed to highlight congruencies, incongruencies, or gaps. These findings informed generation of cross-analytical themes that were transformed into action statements.

Results

The quantitative narrative review of synthesis (n = 17) generated four themes (patients had low awareness of HE and low treatment adherence rates, physicians had a non-uniform approach to non-pharmaceutical therapies). Meta-aggregation of qualitative data from six articles yielded three themes (patients and care partners had low levels of HE awareness, were unfamiliar with HE self-management, and were adherent to treatments). Comparison of findings revealed three congruencies, two gaps, and one incongruency. The combined synthesis yielded two self-management themes: universal patient-oriented cirrhosis HE education and ensuring each health care encounter systematically addresses HE to guarantee health care is continuously modified to meet their needs.

Conclusions

By drawing on elements of Bloom's Taxonomy and distributed knowledge networks, deliberate patient-oriented HE messaging at all health care encounters is greatly needed to improve health outcomes and reduce care burdens related to HE.

The tele-liver frailty index (TeLeFI): development of a novel frailty tool in patients with cirrhosis via telemedicine

Frailty is a critical determinant of outcomes in cirrhosis patients. The increasing use of telemedicine has created an unmet need for virtual frailty assessment. We aimed to develop a telemedicine-enabled frailty tool (tele-liver frailty index). Adults with cirrhosis in the liver transplant setting underwent ambulatory frailty testing with the liver frailty index (LFI) in-person, then virtual administration of (1) validated surveys (eg, SARC-F and Duke Activity Status Index [DASI]), (2) chair stands, and (3) balance. Two models were selected and internally validated for predicting LFI ≥4.4 using: (1) Bayesian information criterion (BIC), (2) C-statistics, and (3) ease of use. Of 145 patients, the median (interquartile range) LFI was 3.7 (3.3-4.2); 15% were frail. Frail (vs not frail) patients reported significantly greater impairment on all virtually assessed instruments. We selected 2 parsimonious models: (1) DASI + chair/bed transfer (SARC-F) (BIC 255, C-statistics 0.78), and (2) DASI + chair/bed transfer (SARC-F) + virtually assessed chair stands (BIC 244, C-statistics 0.79). Both models had high C-statistics (0.76-0.78) for predicting frailty. In conclusion, the tele-liver frailty index is a novel tool to screen frailty in liver transplant patients via telemedicine pragmatically and may be used to identify patients who require in-person frailty assessment, more frequent follow-up, or frailty intervention.

Pharmacokinetics of AXA1665, a Novel Composition of Amino Acids, in Comparison With Protein Supplement: A Single-Dose, Open-Label, Randomized Study in Healthy Subjects

We evaluated the safety and tolerability of AXA1665, a novel investigational fixed-ratio amino acid (AA) composition, the pharmacokinetics (PK) of the constituent AAs within AXA1665, and their relative bioavailability versus standard protein supplement. This study was conducted in 2 phases; in the initial phase, healthy subjects (N = 16) were randomly assigned to 4 treatment sequences (AXA1665 4.9, 9.8, and 19.6 g or 35 g protein supplement) in an open-label, single-dose, 4-way crossover study, while in the extension phase, they received single AXA1665 doses of 29.4 and 39.2 g in a sequential crossover manner. The net area under the plasma concentration-time curve (AUC) and observed time to reach maximum plasma concentration were estimated. A dose-dependent increase in plasma AUC from time 0 to the last measurable concentration (AUClast ) and maximum plasma concentration (Cmax ) was observed for all AXA1665-dosed AAs (4.9-39.2 g) except aspartic acid. AXA1665 19.6 g resulted in 1.5- to 9.5-fold higher systemic exposure to all AXA1665-dosed AAs except for aspartic acid and lysine and lower exposure to all nondosed AAs except for glutamine and alanine versus protein supplement. AXA1665 doses, up to 39.2 g, can deliver AXA1665-dosed AAs in the systemic circulation in the linear AUC range.

Challenges in Diagnosis and Therapeutic Approach of Acute on Chronic Liver Failure-A Review of Current Evidence

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute and severe decompensation of chronic liver disease (CLD) correlated with multiple organ failure, poor prognosis, and increased mortality. In 40-50% of ACLF cases, the trigger is not recognized; for many of these patients, bacterial translocation associated with systemic inflammation is thought to be the determining factor; in the other 50% of patients, sepsis, alcohol consumption, and reactivation of chronic viral hepatitis are the most frequently described trigger factors. Other conditions considered precipitating factors are less common, including acute alcoholic hepatitis, major surgery, TIPS insertion, or inadequate paracentesis without albumin substitution. Host response is likely the primary factor predicting ACLF severity and prognosis, the host immune response having a particular significance in this syndrome, together with the inflammatory cascade. The management of ACLF includes both the prevention of the precipitating factors that lead to acute liver decompensation and the support of vital functions, the prevention and management of complications, the estimation of prognosis, and the opportunity for liver transplantation.

From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients

Liver transplantation (LT) is a complex surgical procedure requiring thorough pre- and post-operative planning and care. The nutritional status of the patient before, during, and after LT is crucial to surgical success and long-term prognosis. This review aims to assess nutritional status assessment and management before, during, and after LT, with a focus on patients who have undergone bariatric surgery. We performed a comprehensive topic search on MEDLINE, Ovid, In-Process, Cochrane Library, EMBASE, and PubMed up to March 2023. It identifies key factors influencing the nutritional status of liver transplant patients, such as pre-existing malnutrition, the type and severity of liver disease, comorbidities, and immunosuppressive medications. The review highlights the importance of pre-operative nutritional assessment and intervention, close nutritional status monitoring, individualised nutrition care plans, and ongoing nutritional support and monitoring after LT. The review concludes by examining the effect of bariatric surgery on the nutritional status of liver transplant recipients. The review offers valuable insights into the challenges and opportunities for optimising nutritional status before, during, and after LT.

The relationship between sarcopenia, multidimensional frailty, and malnutrition cluster and long‐term mortality in hospitalized patients with cirrhosis

Aim

Sarcopenia, multidimensional frailty, and malnutrition represent common debilitating conditions in the context of cirrhosis, linked to a variety of dismal outcomes. We aimed to clarify their overlap and cumulative impact on long‐term mortality in hospitalized patients with cirrhosis.

Methods

Consecutive patients with cirrhosis were prospectively recruited from January 2018 to December 2020. The diagnosis of sarcopenia, multidimensional frailty, and malnutrition was standardized according to the consensus definition and our well‐documented criteria. The prevalence of the respective debilitating condition and the concurrence of this comorbidity were calculated.

Results

In total, 253 patients with cirrhosis aged 64 years with a female predominance (52.4%) were recruited. Sarcopenia was present in 20.9% (53/253), multidimensional frailty in 12.6% (32/253), and malnutrition in 44.7% (113/253) of the entire cohort. Approximately half of the patients had at least one debilitating condition (127/253). Sarcopenia and malnutrition co‐existed in 33 nonfrail patients (13.0%) and multidimensional frailty and malnutrition in eight nonsarcopenic patients (3.2%). Fifteen (5.9%) subjects had all three debilitating conditions, namely malnutrition, sarcopenia, and frailty (MSF) group. The proportions of males, infections, and ascites were significantly higher in the MSF group. Patients in the MSF group had the highest levels of neutrophil‐to‐lymphocyte ratio and creatinine. The 2‐year mortality rates in patients with three debilitating conditions, two conditions, one condition, and no conditions were 60.0%, 23.8%, 21.4%, and 13.5%, respectively. Multivariate Cox regression indicated the long‐term mortality risk was approximately four‐fold higher among patients in the MSF group compared to those with no conditions.

Conclusions

A fraction of patients with cirrhosis exhibited comorbidities of sarcopenia, multidimensional frailty, and malnutrition, linked to a higher risk of long‐term mortality.

The use of phase angle in patients with digestive and liver diseases

Diseases of the liver and the digestive system can lead to malnutrition through an action of reduced food intake or nutrient use, inflammation and impaired metabolism, which result in substantial changes in body composition. Frequently, malnutrition manifests itself with weight loss and reduced muscle mass. However, weight loss and body mass index lack sensitivity to detect the loss of muscle mass and are not informative in distinguishing body water compartments and in characterizing their distribution. This issue is particularly relevant to these two disease models, which are frequently associated with fluid volume imbalances. Phase angle is a useful indicator for cell membrane integrity, water distribution between the intracellular and extracellular spaces and prediction of body cell mass as it is described by measured components of electrical impedance. Malnutrition, inflammation and oxidative stress impair electric tissue properties leading to lower values of PhA. In patients with inflammatory bowel and liver diseases, PhA was consistently found to be related to nutritional status and body composition, particularly the depletion of lean body mass and sarcopenia. It has been associated with prognosis, disease stage and severity and found to be helpful in monitoring fluid shifts and response to interventions.

Liver transplantation in the patient with physical frailty

Frailty is a decline in functional reserve across multiple physiological systems. A key component of frailty is sarcopenia, which denotes a loss of skeletal muscle mass and impaired contractile function that ultimately result in physical frailty. Physical frailty/sarcopenia are frequent and contribute to adverse clinical outcomes before and after liver transplantation. Frailty indices, including the liver frailty index, focus on contractile dysfunction (physical frailty), while cross-sectional image analysis of muscle area is the most accepted and reproducible measure to define sarcopenia. Thus, physical frailty and sarcopenia are interrelated. The prevalence of physical frailty/sarcopenia is high in liver transplant candidates and these conditions have been shown to adversely impact clinical outcomes including mortality, hospitalisations, infections, and cost of care both before and after transplantation. Data on the prevalence of frailty/sarcopenia and their sex- and age-dependent impact on outcomes are not consistent in patients on the liver transplant waitlist. Physical frailty and sarcopenic obesity are frequent in the obese patient with cirrhosis, and adversely affect outcomes after liver transplantation. Nutritional interventions and physical activity remain the mainstay of management before and after transplantation, despite limited data from large scale trials. In addition to physical frailty, there is recognition that a global evaluation including a multidisciplinary approach to other components of frailty (e.g., cognition, emotional, psychosocial) also need to be addressed in patients on the transplant waitlist. Recent advances in our understanding of the underlying mechanisms of sarcopenia and contractile dysfunction have helped identify novel therapeutic targets.

Proceedings of the 27th Annual Congress of the International Liver Transplantation Society

After a virtual congress in 2021 and a previous absence in 2020 because of the coronavirus disease 2019 pandemic, the 27th Annual Congress of the International Liver Transplantation Society was held from May 4 to 7, 2022, in a hybrid format in Istanbul, with 1123 (58% on-site) liver transplant professionals from 61 countries attending the meeting. The hybrid format successfully achieved a balance of much yearned-for "in-person interaction" and global online participation. Almost 500 scientific abstracts were presented. In this report, the Vanguard Committee aims to present a summary of key invited lectures and selected abstracts for the liver transplant community.

Branched-chain amino acids supplementation improves liver frailty index in frail compensated cirrhotic patients: a randomized controlled trial

BACKGROUND

Physical frailty is related with morbidity and mortality in patients with cirrhosis. Currently, there is no approved treatment of frailty in these patients. Here, we evaluated the efficacy of 16 weeks branched-chain amino acids (BCAA) supplementation on frailty in frail compensated cirrhotic patients.

METHODS

After a 4-week run-in period consisted of dietary and exercise counseling, compensated cirrhotic patients with frailty, defined by liver frailty index (LFI)≥4.5, were randomly assigned (1:1) to BCAA or control group. The BCAA group received twice daily BCAAs supplementation (210 kcal, protein 13.5 g, BCAA 2.03 g) for 16 weeks. The primary outcome was frailty reversion. The secondary outcomes were changes in biochemistries, body composition evaluated by bioelectrical impedance analysis, and quality of life (QoL).

RESULTS

54 patients were prospectively enrolled (age 65.5 ± 9.9 years, 51.9% female, Child-Pugh A/B 68.5%/31.5%, MELD 10.3 ± 3.1). Baseline characteristics were similar between both groups. At week 16, BCAA group had a significant improvement in LFI (-0.36 ± 0.3 vs. -0.15 ± 0.28, P = 0.01), BMI (+ 0.51 ± 1.19 vs. -0.49 ± 1.89 kg/m², P = 0.03), and serum albumin (+ 0.26 ± 0.27 vs. +0.06 ± 0.3 g/dl, P = 0.01). The proportion of frailty reversion at week 16 was significantly higher in BCAA group (36% vs. 0%, P < 0.001). Compared with baseline, BCAA group had a significant increase in skeletal muscle index (7.5 ± 1.6 to 7.8 ± 1.5 kg/m², P = 0.03). Regarding the QoL, only the BCAA group had a significant improvement in all 4 domains of physical component score of the SF-36 questionnaire.

CONCLUSIONS

A 16-week BCAA supplementation improved frailty in frail compensated cirrhotic patients. In addition, this intervention resulted in an improvement of muscle mass and physical domain of QoL in these patients.

TRIAL REGISTRATION

This study was registered with Thai Clinical Trial Registry (TCTR20210928001; https://www.thaiclinicaltrials.org/# ).

Evaluation of handgrip strength as a predictor of sarcopenia in patients with HCV-related cirrhosis

Background

Sarcopenia, characterised by a loss of muscle strength, quantity/quality, and physical performance, is associated with increased mortality and poor clinical outcomes in patients with liver cirrhosis. The use of the currently accepted methods for estimating muscle mass, such as computed tomography, dual-energy X-ray absorptiometry, and bioelectrical impedance analysis, in routine clinical practice is restricted because of limited availability, radiation exposure, time consumption, or high cost. Therefore, an alternative, simple, safe, reproducible, and financially accessible method for the routine assessment of sarcopenia is needed. Hence, we aim to assess the utility of handgrip strength (HGS) in diagnosing sarcopenia in patients with HCV-related cirrhosis compared to appendicular skeletal muscle index assessed by dual-energy X-ray absorptiometry (DEXA-ASMI). A total of 64 participants older than 18 years were consecutively recruited. The subjects were divided into the following groups: Control group included 32 healthy control subjects, and the HCV-related liver cirrhosis group included 32 patients who were subdivided equally into two subgroups (Child A and Child C) with 16 patients each. All participants were subjected to dominant hand dynamometer and DEXA scan.

Results

The prevalence of sarcopenia was significantly higher in the cirrhosis group than in the control group (7.75 ± 1.35 vs. 8.29 ± 1.25 kg/m2, P < 0.001), with increasing prevalence in the Child C class group (P < 0.001). HGS was significantly lower in the Child C group compared to other groups (P < 0.001). Regarding the differentiation of sarcopenic patients, defining HGS using a cutoff of ≤ 28.6 kg has an AUC of 0.879, sensitivity of 100%, specificity of 66.7%, PPV of 61.1%, and NPV of 100% (95% CI = 0.715 to 0.967; P < 0.0001).

Conclusion

Given the low cost, reproducibility, and safety of handgrip strength dynamometry, this is a promising method for both the diagnosis of sarcopenia as well as serial monitoring of muscle function in patients with HCV-related cirrhosis.

Diagnosis and Management of Cirrhosis and Its Complications: A Review

Importance

Cirrhosis affects approximately 2.2 million adults in the US. From 2010 to 2021, the annual age-adjusted mortality of cirrhosis increased from 14.9 per 100 000 to 21.9 per 100 000 people.

Observations

The most common causes of cirrhosis in the US, which can overlap, include alcohol use disorder (approximately 45% of all cases of cirrhosis), nonalcoholic fatty liver disease (26%), and hepatitis C (41%). Patients with cirrhosis experience symptoms including muscle cramps (approximately 64% prevalence), pruritus (39%), poor-quality sleep (63%), and sexual dysfunction (53%). Cirrhosis can be diagnosed by liver biopsy but may also be diagnosed noninvasively. Elastography, a noninvasive assessment of liver stiffness measured in kilopascals, can typically confirm cirrhosis at levels of 15 kPa or greater. Approximately 40% of people with cirrhosis are diagnosed when they present with complications such as hepatic encephalopathy or ascites. The median survival time following onset of hepatic encephalopathy and ascites is 0.92 and 1.1 years, respectively. Among people with ascites, the annual incidence of spontaneous bacterial peritonitis is 11% and of hepatorenal syndrome is 8%; the latter is associated with a median survival of less than 2 weeks. Approximately 1% to 4% of patients with cirrhosis develop hepatocellular carcinoma each year, which is associated with a 5-year survival of approximately 20%. In a 3-year randomized clinical trial of 201 patients with portal hypertension, nonselective β-blockers (carvedilol or propranolol) reduced the risk of decompensation or death compared with placebo (16% vs 27%). Compared with sequential initiation, combination aldosterone antagonist and loop diuretics were more likely to resolve ascites (76% vs 56%) with lower rates of hyperkalemia (4% vs 18%). In meta-analyses of randomized trials, lactulose was associated with reduced mortality relative to placebo (8.5% vs 14%) in randomized trials involving 705 patients and reduced risk of recurrent overt hepatic encephalopathy (25.5% vs 46.8%) in randomized trials involving 1415 patients. In a randomized clinical trial of 300 patients, terlipressin improved the rate of reversal of hepatorenal syndrome from 39% to 18%. Trials addressing symptoms of cirrhosis have demonstrated efficacy for hydroxyzine in improving sleep dysfunction, pickle brine and taurine for reducing muscle cramps, and tadalafil for improving sexual dysfunction in men.

Conclusions and Relevance

Approximately 2.2 million US adults have cirrhosis. Many symptoms, such as muscle cramps, poor-quality sleep, pruritus, and sexual dysfunction, are common and treatable. First-line therapies include carvedilol or propranolol to prevent variceal bleeding, lactulose for hepatic encephalopathy, combination aldosterone antagonists and loop diuretics for ascites, and terlipressin for hepatorenal syndrome.

Medical malpractice claims in Hepatology: Rates, Reasons, and Results

BACKGROUND

Clinicians are motivated to provide safe, high-quality care to patients with chronic liver disease. This includes the desire to avoid litigation. Data are limited regarding the actual sources of medicolegal risk in chronic liver disease.

METHODS

We conducted a review of a national liability insurer (Candello) with an additional granular analysis of our institution's registry of liability claims. We included closed cases involving chronic liver disease-related encounters between 2012 and 2021. We determined rates of legal claims from a denominator of unique patients with cirrhosis or transplant care seen over the study period.

RESULTS

Local database: We retrieved 39 claims of which 15 involved patients with non-cirrhotic chronic liver disease, 13 involved cirrhosis (0.06% incidence), and 11 involved patients who underwent transplantation (0.6% incidence). Most claims involved periprocedural complications. Others included adverse reactions to prophylactic plasma transfusion, medication-induced HE, and falls/fractures.

NATIONAL DATABASE

We found 94 claims related to liver disease out of 102,575 (0.09%) total claims. Overall, 56% involved diagnosis-related issues (failure/delay in ordering a diagnostic test, failure to appreciate and reconcile a symptom/sign or result, or the misinterpretation of a diagnostic study). Miscommunication between providers and between providers and patients was implicated in 22% of cases. Patient behavior-related factors (nonadherence with scheduled appointments, treatments, or diagnostic testing) factored in 20% of cases. Selection or the management of therapy played a role in 7% of cases. Very rarely were cases associated with technical skill (4%), house staff supervision (3%), or weekend/holiday care (1%). Fifty-one (55%) claims involved HCC.

CONCLUSION

We provide the rates and reasons for medical malpractice claims in hepatology.

Sarcopenia in cirrhosis: epidemiology, diagnosis, management and prognosis

PURPOSE OF REVIEW

With the development of many international guidelines, research on sarcopenia has increased rapidly, showing that sarcopenia is predictive of adverse outcomes, including increased mortality and impaired mobility, in patients with cirrhosis. The purpose of this article is to review the current evidence concerning the epidemiology, diagnosis, management and predictive value of sarcopenia on the prognosis of patients with cirrhosis.

RECENT FINDINGS

Sarcopenia is a frequent and lethal complication of cirrhosis. Currently, abdominal computed tomography imaging is the most commonly used method to diagnose sarcopenia. In clinical practice, assessing muscle strength and physical performance, such as by measuring handgrip strength and gait speed, is of increasing interest. In addition to the necessary pharmacological therapy, adequate intake of protein, energy and micronutrients, as well as regular moderate-intensity exercise, can help to minimize sarcopenia. Sarcopenia has been shown to be a strong predictor of prognosis in patients with severe liver disease.

SUMMARY

A global consensus is needed on the definition and operational parameters for the diagnosis of sarcopenia. Further research should focus on developing standardized screening, management and treatment protocols for sarcopenia. Adding sarcopenia to existing models may better exploit the effect of sarcopenia on prognosis in patients with cirrhosis, which should be investigated further.

Critical Care Management of Acute-on-Chronic Liver Failure: Certainties and Unknowns

Intensive care unit (ICU) admission is frequently required in patients with decompensated cirrhosis for organ support. This entity, known as acute-on-chronic liver failure (ACLF), is associated with high short-term mortality. ICU management of ACLF is complex, as these patients are prone to develop new organ failures and infectious or bleeding complications. Poor nutritional status, lack of effective liver support systems, and shortage of liver donors are also factors that contribute to increase their mortality. ICU therapy parallels that applied in the general ICU population in some complications but has differential characteristics in others. This review describes the current knowledge on critical care management of patients with ACLF including organ support, prognostic assessment, early liver transplantation, and futility rules. Certainties and knowledge gaps in this area are also discussed.

Relationship between lipid profiles and reduced handgrip strength (dynapenia) in hospitalized patients with cirrhosis

BACKGROUND

Dynapenia embraces clinical significance and predictive value separated from skeletal muscle loss among cirrhosis. Moreover, alterations in lipid levels may impact muscle function. It has yet to elucidate the relationship between lipid profiles and muscle strength weakness. We sought to explore which lipid metabolism indicator could be useful to identify patients with dynapenia in daily practice.

METHODS

A retrospective observational cohort study enrolling 262 cirrhotic patients. Analysis of the receiver operating characteristic (ROC) curve was performed to determine the discriminatory cutoff for dynapenia. Multivariate logistic regression was conducted to assess the association between total cholesterol (TC) and dynapenia. Also, we established a model based on the classification and regression tree method.

RESULTS

ROC implicated a cutoff of TC ≤ 3.37 mmol/L to identify dynapenia. Patients with TC ≤ 3.37 mmol/L showed significantly lower handgrip strength (HGS; 20.0 vs. 24.7 kg, P  = 0.003), lower hemoglobin, lower platelet, lower white blood cell count, lower sodium and higher prothrombin-international normalized ratio. A positive correlation was found between TC and HGS values ( r  = 0.1860, P  = 0.003). TC remained a significant association with dynapenia after controlling for variables including age, sex, BMI, and the presence of ascites. The decision tree incorporating TC, BMI, and age had a sensitivity of 71.4%, specificity of 64.9%, and an area under ROC of 0.681.

CONCLUSION

TC ≤ 3.37 mmol/L was significantly associated with the presence of dynapenia. Assessing TC may be helpful for identifying dynapenic patients with cirrhosis in the health care or hospital setting.

Prognostic significance of sarcopenia and severe vitamin D deficiency in patients with cirrhosis

Background and Aim

Sarcopenia and severe vitamin D deficiency are associated with malnutrition and poor prognosis. We investigated the impact of the comorbidity of Child-Pugh (CP) class B/C cirrhosis and the aforementioned complications on the prognosis of patients with cirrhosis.

Methods

We retrospectively evaluated 104 patients with cirrhosis. The cumulative survival rates were compared between patients with and without both or either of these disease conditions: CP class B/C and complications (sarcopenia or severe vitamin D deficiency). Sarcopenia was diagnosed according to the Japan Society of Hepatology criteria. Severe vitamin D deficiency was defined as levels of 25-hydroxyvitamin D <10 ng/mL in serum.

Results

The prevalence of CP class B/C, sarcopenia, and severe vitamin D deficiency was 26.9%, 38.5%, and 24.0%, respectively. Patients with both CP class B/C and sarcopenia had significantly lower survival rates than those without both (hazard ratio [HR] = 6.101; P < 0.001) and with either condition (HR = 6.137; P = 0.001). Similarly, patients with both CP class B/C and severe vitamin D deficiency or with either condition had significantly lower survival rates than those without both conditions (HR = 8.135 or 3.189; P < 0.001 or =0.025, respectively). CP class B/C (HR = 3.354; P = 0.006) and severe vitamin D deficiency (HR = 2.445; P = 0.044) were independent prognostic factors.

Conclusions

The coexistence of CP class B/C and sarcopenia or severe vitamin D deficiency worsened the prognosis of patients with cirrhosis. Nutritional assessments such as sarcopenia and vitamin D status should be considered to better evaluate disease conditions and patient prognosis.

Nutritional and Lifestyle Therapy for NAFLD in People with HIV

HIV infection and nonalcoholic fatty liver disease (NAFLD) are two major epidemics affecting millions of people worldwide. As people with HIV (PWH) age, there is an increased prevalence of metabolic comorbidities, along with unique HIV factors, such as HIV chronic inflammation and life-long exposure to antiretroviral therapy, which leads to a high prevalence of NAFLD. An unhealthy lifestyle, with a high dietary intake of refined carbohydrates, saturated fatty acids, fructose added beverages, and processed red meat, as well as physical inactivity, are known to trigger and promote the progression of NAFLD to nonalcoholic steatohepatitis, liver fibrosis, and hepatocellular carcinoma. Furthermore, with no currently approved pharmacotherapy and a lack of clinical trials that are inclusive of HIV, nutritional and lifestyle approaches still represent the most recommended treatments for PWH with NAFLD. While sharing common features with the general population, NAFLD in PWH displays its own peculiarities that may also reflect different impacts of nutrition and exercise on its onset and treatment. Therefore, in this narrative review, we aimed to explore the role of nutrients in the development of NAFLD in PWH. In addition, we discussed the nutritional and lifestyle approaches to managing NAFLD in the setting of HIV, with insights into the role of gut microbiota and lean NAFLD.

Prevalence and prognosis of Computed-Tomography defined sarcopenia in Tunisian cirrhotic patients

INTRODUCTION

Sarcopenia is an underdiagnosed and understudied complication of cirrhosis, especially in patients not undergoing liver transplantation.

AIM

To evaluate the prevalence and prognostic impact of radiological sarcopenia in non-transplanted cirrhotic patients.

METHODS

Longitudinal retrospective study including cirrhotic patients explored by an abdominal CT scan, over a period of 6 years, in a single gastroenterology department in Tunisia. Sarcopenia was defined according to transversal psoas muscle thickness normalized to height (TPMT/h) in the sagittal CT slice. Two groups were defined: Group 1 with sarcopenia (TPMT/h <16.8mm/m); and Group 2 without sarcopenia (TPMT/h ≥16.8mm/m).

RESULTS

Seventy patients were included (mean age=62 years). The mean MELD score was 12.81 and the mean TPMT/h of 13.56 mm/m. Forty-four patients were sarcopenic (63%). When included, the 2 groups' baseline characteristics were comparable except for women predominance and refractory ascites in group 1. After an average of 21-month follow-up, sarcopenia was associated with a higher number of complications per patient (p=0.013) and a longer average hospital stay duration per patient (p=0.001). Overall survival was significantly decreased in sarcopenic patients (p=0.035). Survival rates at 6 months, 1 year, and 2 years were respectively 42%, 30%, and 24% in Group 1 versus 67%, 40%, and 27% in Group 2. Sarcopenia was an independent factor of mortality in multivariate analysis (OR=2.5; 95% IC [1.02-6.16]; p=0.045).

CONCLUSION

Sarcopenia is frequent and an independent poor prognostic factor in cirrhosis. TPMT/h is an easy and often available method for sarcopenia diagnosis.

Consider hospice in end-stage liver disease prognostic scale to open discussions regarding six-month mortality

Background and Aim

Hospice is underutilized in the management of patients with end-stage liver disease and may improve the patient experience at the end of life. This study aims to create a novel prognostic scale to accurately predict 6-month mortality to more comprehensively facilitate hospice referral.

Methods

Sociodemographic, clinical, and laboratory variables associated with mortality from the United Network for Organ Sharing database were tested in univariate analysis followed by multivariate analyses with four predictor groups: Demographics, Diagnoses, Complexities, and Laboratory studies to develop the hospice in end-stage liver disease prognostic scale (HELP) scale (70% sample, N = 13 516) followed with replication in a 30% (N = 5792) internal validation sample.

Results

Only the predictor groups of Complexities and Laboratory studies met the c-statistic threshold of 0.70 for inclusion in the multivariate analyses. Backward elimination in the final logistic regression and validated weighted transformation procedure resulted in: HELP scale = (functional status × 11) + (ascites × 3) + (SBP × 3) + (HE × 4) + (dialysis × 5) + (TIPS × -3) + (albumin × -3) + (MELD-Na ≥ 21 × 20). HELP scale had a strong predictive value for six-month mortality with Area under the Receiver Operating Curve (AUROC) 0.816 and replicated in the validation sample.

Conclusion

HELP scale is a novel prognostic score utilizing the strength of model of end-stage liver disease-sodium (MELD-Na), along with clinical factors, for a more nuanced assessment of six-month mortality. This scale can provide an individualized approach in opening discussions of hospice referral and may be better accepted by patients and providers given its contextualization of important clinical factors.

Sarcopenia Defined by Psoas Muscle Thickness Predicts Mortality After Transjugular Intrahepatic Portosystemic Shunt

PURPOSE

To assess and compare the value of psoas muscle thickness at the level of the third lumbar (L3) vertebra (TPML) or umbilicus (TPMU) and skeletal muscle index (SMI) for diagnosing sarcopenia and predicting mortality in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS).

MATERIALS AND METHODS

Two hundred forty-nine patients undergoing TIPS were included in this retrospective study. The cut-offs of L3-SMI for sarcopenia were 42.0 cm2/m2 in men and 38.0 cm2/m2 in women. The cut-offs for TPML/height and TPMU/height to predict mortality was established using a receiver-operating characteristic analysis. The Kaplan-Meier and Cox regression were used for survival analyses.

RESULTS

Compared with TPMU/height, TPML/height was more consistent with L3-SM for the diagnosis of sarcopenia (Kappa coefficient: 0.63 vs. 0.36 in men; 0.61 vs. 0.45 in women). The Cox analysis showed that both TPML/height and TPMU/height were independent risk factors for mortality. The optimal cut-off values of TPML/height and TPMU/height for mortality in men and women were 11.2 mm/m, 9.4 mm/m, 18.4 mm/m, 15.1 mm/m, respectively. There were 119 (47.8%), 87 (34.9%), and 82 (32.9%) patients diagnosed with sarcopenia in the TPMU/height, TPML/height, and L3-SMI models, respectively. Kaplan-Meier analysis showed that the overall survival was significantly lower in the sarcopenia group in all three models.

CONCLUSION

TPMU/height and TPML/height have a similar survival prognostic value as L3-SMI. TPML/height has better consistency with L3-SMI in diagnosing sarcopenia and is a more stable alternative to L3-SMI for diagnosing sarcopenia in patients undergoing TIPS.

Nutrition and physical activity knowledge, attitudes, and practices of inpatient cirrhosis care providers

BACKGROUND

Hospitalization is a high-risk period for cirrhosis-associated sarcopenia and frailty. This study aimed to measure the knowledge, attitudes, and practice patterns (KAP) of multidisciplinary cirrhosis providers about inhospital nutrition and physical activity care.

METHODS

We conducted an online survey of cirrhosis care providers at a combination of 38 hospitals and healthcare centres in Alberta, Canada. Analysis included descriptive statistics and content analysis.

RESULTS

Three hundred thirty-eight responses were analyzed. Across all providers, nutrition and physical activity knowledge and attitude (KA) scores were higher than practice (P) scores. Physicians had lower nutrition KA ( P = 0.010) and nutrition P ( P < 0.001) scores than nonphysicians. Previous cirrhosis-related nutrition or physical activity education was associated with higher nutrition KA ( P < 0.001), nutrition P ( P = 0.036), and physical activity P scores ( P < 0.001). Over half of the participants reported not providing patients with educational resources for nutrition or physical activity and not carrying out nutrition screening. Participant suggestions to optimize care included enhancing patient and provider education, standardizing screening and intervention processes, increasing patient-centered support, and promoting collaboration within the healthcare team. Eighty percentage of participants were willing to provide patients with resources if these were readily available.

CONCLUSION

While provider knowledge and attitudes about the importance of nutrition and physical activity in hospitalized patients with cirrhosis are reasonable, there is considerable room to optimize the delivery of best practices in this patient population. Optimization will require readily available educational and personnel resources and interdisciplinary collaboration to promote system change.

Frailty as tested by the Liver Frailty Index in out-patient patients with cirrhosis in China: a cross-sectional study

BACKGROUND

Early identification and prevention of frailty are very important for patients with cirrhosis.

METHODS

The study was the first to use Liver Frailty Index in out-patient patients with cirrhosis in China, and to analyze the influencing factors.

RESULT

This study included 387 patients with cirrhosis. Frailty was diagnosed using the Liver Frailty Index. Multiple Logistic regression model were used to analyze influencing factors of frailty in out-patient patients with cirrhosis. Frailty was diagnosed in 9.6% of patients and prefrailty was diagnosed in 54.8% of patients. Age, sex, BMI, education level, monthly economic income, number of unplanned hospital admissions in the past year, cause of cirrhosis, Child-Pugh classification of cirrhosis, nutritional risk, physical activity, gait speed and Activity of Daily Living (ADL) Scale in the frailty, prefrailty and no frailty of groups were statistically significant. Age (OR, 1.103; CI, 0.064-0.132), BMI (OR, 0.817; CI, -0.302 to -0.104), education level (OR, 4.321; CI, 0.754-2.173), physical activity (OR, 3.580; CI, 0.534-2.016) and gait speed (OR, 0.001; CI, -8.188 to -4.972) were influential factors of frailty in out-patient patients with cirrhosis.

CONCLUSION

Out-patient patients with cirrhosis have a high incidence of frailty and prefrailty. Elderly, reduced gait speed, no physical activity and low culture level are risk factors for frailty and prefrailty, and we should be identification and intervention early.

Predicting dry weight in patients with cirrhotic ascites undergoing large-volume paracentesis

BACKGROUND & AIMS

Ascites impairs the correct diagnosis and nutritional management in patients with cirrhosis, because the body weight, which is needed for nutritional assessment and calculation of nutritional needs, is overestimated. To adjust the weight in patients with ascites, dietetic guidances indicate substracting 2.2-14 kg or 5-15% of the measured body weight according to the degree of ascites, however, there is a lack of evidence to substantiate these values. The aim of this study was to develop new prediction equations to estimate the dry weight, comparing them with the currently used weight adjustments in patients with refractory cirrhotic ascites.

METHODS

Cross-sectional study, that included patients with decompensated cirrhosis undergoing large-volume paracentesis. Patients were submitted to nutritional risk screening, nutritional assessment, and anthropometric measurements that included body weight, abdominal circumference (both measured before and after paracentesis) height, and upper mid-arm circumference. The volume of ascitic fluid drained was also registered. For the predictions of dry weight, linear regression models were performed using as predictor variables: height, pre-paracentesis weight, pre-paracentesis abdominal circumference, or mid-upper arm circumference, and as response variable: post-paracentesis weight. The capacity of these models to predict the post-paracentesis weight was evaluated by comparing it with the currently used predictions through the intraclass correlation coefficient (ICC) and the mean squared error (MSE).

RESULTS

Nineteen patients were included, 15 male, and 18 with high nutritional risk and malnutrition. The difference between post-paracentesis weight and pre-paracentesis weight was -5.0 (-3.6 to -9.9) kg, similar to ascitic fluid volume drained. Two equations were developed to predict post-paracentesis weight. ICC values showed that both prediction equations were strongly correlated (r > 0.94) with post-paracentesis weight. Our models also showed lower MSEs (<17.97), compared with the current predictions (MSEs <64.19, when the pre-paracentesis weight is adjusted from absolute values and MSEs <33.24 when adjusted from percentage values), indicating a more accurate prediction.

CONCLUSION

The predictive equations from this study may be better options for dry weight estimation in patients with refractory cirrhotic ascites since they showed higher reliability compared to the currently used weight adjustment. External validation in a larger sample is still needed to confirm the clinical applicability of these equations.

Assessing the risk of surgery in patients with cirrhosis

Patients with cirrhosis have an increased perioperative risk relative to patients without cirrhosis. This is related to numerous cirrhosis-specific factors, including severity of liver disease, impaired synthetic function, sarcopenia and malnutrition, and portal hypertension, among others. Nonhepatic comorbidities and surgery-related factors further modify the surgical risk, adding to the complexity of the preoperative assessment. In this review, we discuss the pathophysiological contributors to surgical risk in cirrhosis, key elements of the preoperative risk assessment, and application of risk prediction tools including the Child-Turcotte-Pugh score, Model for End-Stage Liver Disease-Sodium, Mayo Risk Score, and the VOCAL-Penn Score. We also detail the limitations of current approaches to risk assessment and highlight areas for future research.

A Low Daily Intake of Simple Sugars in the Diet Is Associated with Improved Liver Function in Cirrhotic Liver Transplant Candidates

(1) Background: We investigated, for the first time, whether dietary simple sugar intake affects MELD score changes over time in a cohort of cirrhotic liver transplant candidates. (2) Methods: the MELD score, dietary habits using a 3-day food diary, and visceral adipose tissue index (VATI) measured with CT scan were assessed in 80 consecutive outpatient cirrhotic patients at baseline, after counseling to follow current nutritional guidelines. The MELD score was reassessed after six months and the DELTA-MELD was calculated as the MELD at the second assessment minus the MELD at baseline. (3) Results: Compared with the baseline, the MELD score of cirrhotic patients at the end of the study was decreased, stable, or increased in 36%, 8% and 56% of patients, respectively. In separate multiple linear regression models, DELTA-MELD was positively and independently correlated with the daily intake of simple sugars expressed in g/kg body weight (p = 0.01) or as a percentage of total caloric intake (p = 0.0004) and with the number of daily portions of fruit, added sugar, jam, and honey (p = 0.003). These associations were present almost exclusively in patients with VATI above the median value. (4) Conclusions: In cirrhotic patients with high amounts of visceral adipose tissue the consumption of simple sugars and fructose should be limited to improve their clinical outcome.

Sarcopenia negatively affects postoperative short-term outcomes of patients with non-cirrhosis liver cancer

BACKGROUND

Literature review have shown that sarcopenia substantially alters the postoperative outcomes after liver resection for malignant tumors. However, these retrospective studies do not distinguish cirrhotic and non-cirrhotic liver cancer patients, nor combine the assessment of muscle strength in addition to muscle mass. The purpose of this study is to study the relationship between sarcopenia and short-term outcomes after hepatectomy in patients with non-cirrhotic liver cancer.

METHODS

From December 2020 to October 2021, 431 consecutive inpatients were prospectively enrolled in this study. Muscle strength and mass were assessed by handgrip strength and the skeletal muscle index (SMI) on preoperative computed tomographic scans, respectively. Based on the SMI and the handgrip strength, patients were divided into four groups: group A (low muscle mass and strength), group B (low muscle mass and normal muscle strength), group C (low muscle strength and normal muscle mass), and group D (normal muscle mass and strength). The main outcome was major complications and the secondary outcome was 90-d Readmission rate.

RESULTS

After strictly exclusion, 171 non-cirrhosis patients (median age, 59.00 [IQR, 50.00-67.00] years; 72 females [42.1%]) were selected in the final analysis. Patients in group A had a statistically significantly higher incidence of major postoperative complications (Clavien-Dindo classification ≥ III) (26.1%, p = 0.032), blood transfusion rate (65.2%, p < 0.001), 90-day readmission rate (21.7%, p = 0.037) and hospitalization expenses (60,842.00 [IQR, 35,563.10-87,575.30], p < 0.001) than other groups. Sarcopenia (hazard ratio, 4.21; 95% CI, 1.44-9.48; p = 0.025) and open approach (hazard ratio, 2.56; 95% CI, 1.01-6.49; p = 0.004) were independent risk factors associated with major postoperative complications.

CONCLUSIONS

Sarcopenia is closely related to poor short-term postoperative outcomes in non-cirrhosis liver cancer patients and the assessment that combines muscle strength and muscle mass can simply and comprehensively identify it.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers NCT04637048 . (19/11/2020).

Palliative Care for Patients with End-Stage Liver Disease

End-stage liver disease (ESLD) is the culmination of progression of chronic liver disease to cirrhosis, decompensation, and chronic liver failure, featuring portal hypertension or hepatocellular failure-related complications. Liver transplantation offers improved long-term survival for these patients but is negatively influenced by donor availability, financial constraints in developing countries, active substance abuse, progression of disease or malignancy on wait-list, sepsis and extrahepatic organ involvement. In this context, palliative care (PC), an interdisciplinary medical practice that aim to prevent and relieve suffering, offers best possible quality of life and is not limited to end-of-life care. It also encompasses achievable goals such as symptom control and aggressive disease-modifying treatments or interventions that beneficially alter the natural course of the disease to offer curative intend. In this narrative review, we discuss the prognostic factors that define disease course in ESLD, various indications and challenges in PC for advanced cirrhosis and management options for major symptom burden in patients with ESLD based on evidence-based best practice.

Copper deficiency is an independent risk factor for mortality in patients with advanced liver disease

BACKGROUND AND AIM

Copper is an essential trace metal serving as a cofactor in innate immunity, metabolism, and iron transport. We hypothesize that copper deficiency may influence survival in patients with cirrhosis through these pathways.

METHODS

We performed a retrospective cohort study involving 183 consecutive patients with cirrhosis or portal hypertension. Copper from blood and liver tissues was measured using inductively coupled plasma mass spectrometry. Polar metabolites were measured using nuclear magnetic resonance spectroscopy. Copper deficiency was defined by serum or plasma copper below 80 µg/dL for women or 70 µg/dL for men.

RESULTS

The prevalence of copper deficiency was 17% (N=31). Copper deficiency was associated with younger age, race, zinc and selenium deficiency, and higher infection rates (42% vs. 20%, p=0.01). Serum copper correlated positively with albumin, ceruloplasmin, hepatic copper, and negatively with IL-1β. Levels of polar metabolites involved in amino acids catabolism, mitochondrial transport of fatty acids, and gut microbial metabolism differed significantly according to copper deficiency status. During a median follow-up of 396 days, mortality was 22.6% in patients with copper deficiency compared with 10.5% in patients without. Liver transplantation rates were similar (32% vs. 30%). Cause-specific competing risk analysis showed that copper deficiency was associated with a significantly higher risk of death before transplantation after adjusting for age, sex, MELD-Na, and Karnofsky score (HR: 3.40, 95% CI, 1.18-9.82, p=0.023).

CONCLUSIONS

In advanced cirrhosis, copper deficiency is relatively common and is associated with an increased infection risk, a distinctive metabolic profile, and an increased risk of death before transplantation.

[Comparison of different tools for the evaluation of malnutrition and sarcopenia in patients with liver cirrhosis]

INTRODUCTION

malnutrition and sarcopenia are frequent in the population with liver cirrhosis and have a negative impact on the performance status and life expectancy of these patients. There are multiple assessment tools for malnutrition and sarcopenia in cirrhosis.

OBJECTIVE

to assess malnutrition and sarcopenia in liver cirrhosis and to compare the accuracy of diagnostic tools in this population.

METHOD

a cross-sectional analytical study was conducted with convenience sampling by using continuous inclusion of patients with liver cirrhosis in a tertiary care center during December 2018 to May 2019. The nutritional assessment was carried out with arm anthropometry, body mass index (BMI), and the algorithm of the Royal Free Hospital Subjective Global Assessment (RFH-SGA). For the evaluation of sarcopenia, the hand grip strength test with a hand dynamometer was applied. The results were reported in measures of central tendency expressed in frequency and percentage.

RESULTS

a total of 103 patients were included with a predominance of the male gender (79.6 %) and a mean age of 51 years (± 10). The etiology of liver cirrhosis corresponded more frequently to alcohol consumption (68 %) and most of the patients were Child-Pugh C (57.3 %) with a mean MELD of 21.9 (± 8.9). A mean BMI with dry weight of 25.2 kg/m2 was reported, and with respect to the WHO classification by BMI, 7.8 % were underweight and 59.2 % were malnourished by RFH-SGA. Sarcopenia was present in 88.3 % using the hand grip strength test, for which a mean of 18.99 kg was found. A Kendall's Tau-b rank correlation coefficient was performed between BMI and RFH-SGA, which showed no statistically significant association, as well as between mean arm muscle circumference percentiles and hand grip strength.

CONCLUSIONS

global assessment in liver cirrhosis should include screening for malnutrition and sarcopenia, for which validated, accessible and safe application tools should be used, such as anthropometric assessment, RFH-SGA, and hand grip strength.

Systematic review: the role of frailty in advanced chronic liver disease

BACKGROUND

Frailty is a known predictor of outcome and mortality in patients undergoing liver transplantation. However, most patients remain unsuitable transplant candidates. It is not yet known if the assessment of frailty in non-transplant candidates can aid prognostication.

AIM

To collate and interrogate the various frailty tools presently used to predict mortality in the non-transplant cirrhosis setting.

METHODS

A comprehensive review of MEDLINE and EMBASE databases for articles published from inception to March 2022 was undertaken, excluding those where patients underwent transplantation or had hepatocellular carcinoma.

RESULTS

We identified 12 observational cohort studies, featuring 9 frailty indices. These were from various global healthcare settings and of fair or good quality. Most were objective tools utilising clinician-based assessments. All frailty scores predicted prognosis, with variability in the method of application, and utilisation in long- or short-term mortality. Three studies directly compared different indices in the same population. There was some evidence that simple tools could perform as well, if not better, than more complex, time-consuming scores.

CONCLUSIONS

Various frailty tools can reproducibly evaluate mortality in patients with cirrhosis who are ineligible for transplant. However, further prospective head-to-head comparative studies are needed. In addition to determining model utility, studies should focus on important relative considerations which may limit widespread implementation including, ease of use and limited resources, given the global disparity of liver care provision. These tools may positively identify specific patient cohorts at risk of impending deterioration, thereby stratifying those patients likely to benefit from early integration with palliative care.

Waitlist and posttransplantation outcomes of lean individuals with nonalcoholic fatty liver disease

Lean individuals with nonalcoholic fatty liver disease (NAFLD) represent a subset of patients with a distinct risk factor profile. We assessed the association between body mass index (BMI) on waitlist and postliver transplantation (LT) outcomes among these patients. We retrospectively analyzed the United Network for Organ Sharing data, including adult patients with NAFLD listed for LT between February 27, 2002, and June 30, 2020. We first used competing risk analyses to estimate the association of BMI with waitlist removal due to death or clinical deterioration. We then conducted Kaplan-Meier estimates and Cox regression models to determine the impact of weight change during the waiting list on all-cause mortality and graft failure after LT. Patients with normal weight (BMI 18.5-24.9 kg/m 2 ) suffered higher waitlist removal (adjusted subdistribution hazard ratio 1.26, 95% confidence interval [CI] 1.10-1.43; p = 0.001) compared with patients with obesity class I (BMI 30-34.9 kg/m 2 ). Those who remained at normal weight had higher all-cause mortality (adjusted hazard ratio [aHR] 1.61, 95% CI 1.32-1.96; p  <0.001) and graft failure (aHR 1.57, 95% CI 1.32-1.88; p  <0.001) than patients with stable obesity. Among patients with normal weight, those with the greatest weight increase (BMI gain ≥3 kg/m 2 ) had lower all-cause mortality (aHR 0.55, 95% CI 0.33-0.93; p = 0.03) and graft failure (aHR 0.49, 95% CI 0.30-0.81; p = 0.01) compared with patients with stable weight (BMI change ≤1 kg/m 2 ). Patients with NAFLD with normal weight have increased waitlist removal and those who remained at normal weight during the waitlist period have worse posttransplantation outcomes. Identifying and addressing factors influencing apparent healthy weight prior to LT are crucial to mitigate poor outcomes.

The role of transjugular intrahepatic portosystemic shunt in patients with cirrhosis and ascites: Recent evolution and open questions

In selected patients with cirrhosis and ascites, transjugular intrahepatic portosystemic shunt (TIPS) placement improves control of ascites and may reduce mortality. In this review, we summarize the current knowledge concerning the use of TIPS for the treatment of ascites in patients with cirrhosis, from pathophysiology of ascites formation to hemodynamic consequences, patient selection, and technical issues of TIPS insertion. The combination of these factors is important to guide clinical decision-making and identify the best strategy for each individual patient. There is still a need to identify the best timing for TIPS placement in the natural history of ascites (recurrent vs. refractory) as well as which type and level of renal dysfunction is acceptable when TIPS is proposed for the treatment of ascites in cirrhosis. Future studies are needed to define the optimal stent diameter according to patient characteristics and individual risk of shunt-related side effects, particularly hepatic encephalopathy and insufficient cardiac response to hemodynamic consequences of TIPS insertion.