Sarcopenia in Patients with Chronic Liver Disease: Can It Be Altered by Diet and Exercise?

[The role of the musculoadipose status in the assessment of the risk profile before liver transplantation]

Sarcopenia and sarcopenic obesity worsen the prognosis after liver transplantation; however, the assessment of body composition is not yet considered in the evaluation prior to liver transplantation to estimate the risk profile of the recipient. Prehabilitation, which includes the nutritional supplementation and physiotherapy, represents a recent focus of interest in clinical transplantation research. This article gives an overview of the recent knowledge about the role of the musculoadipose status and the available methods for the estimation in the assessment of the recipient's risk profile.

Sarcopenic obesity may predict worse liver regeneration after right graft living donor liver transplantation

Sarcopenic obesity impairs the outcome after liver transplantation. The effect of this on liver regeneration has not yet been studied. The aim of this study was to evaluate the potential effect of body composition changes on liver volume gain after living donor liver transplantation. We observed liver regeneration in 100 patients who underwent living donor liver transplantation using right lobe grafts (Segments V-VIII). Liver volumetry and body composition analysis were performed based on CT images with special software. The gain of liver volume was calculated between 2 points in time considering the absolute and percentage values: before surgery and early after surgery, with a median time of 10 days. Pearson's correlation and multivariate analysis using stepwise multiple regression were used to examine the potential correlation between body composition and liver volume gain. The liver volume increase was significantly negatively correlated with adipose tissue in the body stem ( r = -0.4, p < 0.001) and positively correlated with psoas mass ( r = 0.24, p = 0.02). These results correspond with those of the multiple regression analysis, which indicated adipose tissue (ß = -1.0, p < 0.001) and psoas mass (ß = 0.12, p < 0.001). The presence of malignancy as an indication for liver transplantation was another significant independent factor negatively affecting liver growth (ß = -13.1, p = 0.046). Sarcopenic obesity predicts an impaired liver volume increase after living donation. This could worsen the postoperative outcome. The role of alimentary interventions and exercises in improving body composition and thus postoperative outcome should be evaluated through prospective interventional studies.

Sarcopenia and body fat change as risk factors for radiologic incisional hernia following robotic nephrectomy

OBJECTIVE

To assess the effect of body muscle and fat metrics on the development of radiologic incisional hernia (IH) following robotic nephrectomy.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients who underwent robotic nephrectomy for kidney tumors between 2011 and 2017. All pre- and postoperative CTs were re-reviewed by experienced radiologists for detection of radiologic IH and calculation of the following metrics using Synapse 3D software: cross-sectional psoas muscle mass at the level of L3 and L4 as well as subcutaneous and visceral fat areas. Sarcopenia was defined as psoas muscle index below the lowest quartile. Cox proportional hazard model was constructed to examine the association between muscle and fat metrics and the risk of developing radiologic IH.

RESULTS

A total of 236 patients with a median (IQR) age of 64 (54-70) years were included in this study. In a median (IQR) follow-up of 23 (14-38) months, 62 (26%) patients developed radiologic IH. On Cox proportional hazard model, we were unable to detect an association between sarcopenia and risk of IH development. In terms of subcutaneous fat change from pre-op, both lower and higher values were associated with IH development (HR (95% CI) 2.1 (1.2-3.4), p = 0.01 and 2.4 (1.4-4.1), p < 0.01 for < Q1 and ≥ Q3, respectively). Similar trend was found for visceral fat area changes from pre-op with a HR of 2.8 for < Q1 and 1.8 for ≥ Q3.

CONCLUSION

Both excessive body fat gain and loss are associated with development of radiologic IH in patients undergoing robotic nephrectomy.

Sarcopenia is an independent risk factor for failure to achieve the 1-year MCID of the KOOS, JR and PROMIS PF-SF10a after TKA

BACKGROUND

Sarcopenia, which is a progressive and multifactorial condition of decreased muscle strength, has been identified as an independent predictor for falls, revision, infection, and readmissions following total knee arthroplasty (TKA), but its association to patient reported outcomes (PROMs) is less studied. The aim of this study is to determine if sarcopenia and other measures of body composition are correlated with ability to achieve the 1-year minimal clinically important difference (MCID) of the KOOS JR and PROMIS-PF-SF10a following primary TKA.

METHODS

A multicenter retrospective case-control study was performed. Inclusion criteria consisted of patients over the age of 18 undergoing primary TKA, body composition metrics determined by computed tomography (CT), and available pre- and post-operative PROM scores. Predictors of achievement of the 1-year MCID of the KOOS JR and PROMIS PF-SF-10a were determined through a multivariate linear regression.

RESULTS

140 primary TKAs met inclusion criteria. 74 (52.85%) patients achieved the 1-year KOOS, JR MCID and 108 (77.41%) patients achieved the 1-year MCID for the PROMIS PF-SF10a. Sarcopenia was independently associated with decreased odds of achieving the MCID of both the KOOS, JR (OR 0.31, 95%CI 0.10-0.97, p = 0.04) and the PROMIS-PF-SF10a (OR 0.32, 95%CI 0.12-0.85, p = 0.02) CONCLUSIONS: In our study, sarcopenia was independently associated with increased odds of failure to achieve the 1-year MCID of the KOOS, JR and PROMIS PF-SF10a after TKA. Early identification of sarcopenic patients may be beneficial for arthroplasty surgeons so that targeted nutritional counseling and exercises can be recommended prior to TKA.

Cirrhosis and Sarcopenia

Sarcopenia is a progressive muscle wasting syndrome involving loss in skeletal muscle mass, strength, and function. It is closely associated with cirrhosis and its complications with up to more than half of cirrhotic patients demonstrating imaging findings of sarcopenia. The pathogenesis of this syndrome remains complex, including multiple factors involved in skeletal muscle homeostasis, systemic inflammation, and energy dysregulation. Many modalities exist in assessing and measuring sarcopenia. The use of cross-sectional imaging, such as computed tomography and magnetic resonance imaging, with accurate and clinically proven assessment software should be considered the gold standard. Sarcopenia has become the focus of ongoing extensive research with initial findings highlighting increased mortality and complication rates in patient with cirrhosis and hepatocellular carcinoma. Additional studies have demonstrated reversal and improved survival in sarcopenic patients who have undergone transjugular intrahepatic portosystemic shunt placement. Thus, accounting for sarcopenia can help risk stratify patients prior to interventional procedures to allow for better outcomes and improved survival.

Prognostic significance of sarcopenia in patients with hepatocellular carcinoma treated with lenvatinib: A retrospective analysis

Our study investigated the correlation between sarcopenia and clinical outcomes in patients with hepatocellular carcinoma (HCC) treated with lenvatinib. We retrospectively evaluated 40 consecutive patients with unresectable HCC receiving lenvatinib between November 2018 and May 2020 at the First Hospital of Jilin University. Skeletal muscle mass was measured before treatment initiation. Prognostic significance was assessed with univariate and multivariate Cox proportional hazards models. Overall survival (OS) and progression-free survival (PFS) were evaluated for patients with and without sarcopenia. Sarcopenia was present in 23/40 patients (57.5%). After a median follow-up of 9.2 months, patients with sarcopenia had significantly worse OS and PFS compared with those without sarcopenia (OS: 8.4 months [m] vs 14.7 m, P = .02; PFS: 4.2 m vs 9.0 m, P = .04). Multivariate Cox proportional hazards models identified presence of sarcopenia as an independent risk factor for shorter OS (hazard ratio [HR], 0.257; 95% confidence interval [CI], 0.083-0.794; P = .02). In subgroup analysis, sarcopenia was associated with worse survival than non-sarcopenic patients, irrespective of age, Barcelona clinic liver cancer stage, or albumin-bilirubin grade. Our results show sarcopenia may be a predictor of poor prognosis in patients with HCC receiving lenvatinib. Management of sarcopenia is a vital factor for improving survival outcomes in patients with HCC.

Impact of Sarcopenia and Myosteatosis in Non-Cirrhotic Stages of Liver Diseases: Similarities and Differences across Aetiologies and Possible Therapeutic Strategies

Sarcopenia is defined as a loss of muscle strength, mass and function and it is a predictor of mortality. Sarcopenia is not only a geriatric disease, but it is related to several chronic conditions, including liver diseases in both its early and advanced stages. Despite the increasing number of studies exploring the role of sarcopenia in the early stages of chronic liver disease (CLD), its prevalence and the relationship between these two clinical entities are still controversial. Myosteatosis is characterized by fat accumulation in the muscles and it is related to advanced liver disease, although its role in the early stages is still under researched. Therefore, in this narrative review, we firstly aimed to evaluate the prevalence and the pathogenetic mechanisms underlying sarcopenia and myosteatosis in the early stage of CLD across different aetiologies (mainly non-alcoholic fatty liver disease, alcohol-related liver disease and viral hepatitis). Secondly, due to the increasing prevalence of sarcopenia worldwide, we aimed to revise the current and the future therapeutic approaches for the management of sarcopenia in CLD.

Factors associated with the perceived benefits and barriers to physical activity in liver cirrhosis

OBJECTIVE

To analyze the sociodemographic and clinical factors associated with the perceived benefits and barriers to physical activity (PA) in subjects with liver cirrhosis.

METHODS

This cross-sectional study assessed 102 outpatients with liver cirrhosis regarding the clinical and sociodemographic profile and the perceived benefits and barriers to PA by the Exercise Benefits and Barriers Scale and muscle strength. A Generalized Step-Forward linear regression analysis was used to identify the factors associated.

RESULTS

The participants were 59±10 years and 60.8% were men. Around 29.4% had ascites decompensation. Perceived benefits and barriers were associated with the presence of ascites (95%CI -0.079 - 0.03; p=0.06 and 95%CI 0.003 - 0.217; p=0.045, respectively). In the group with ascites, both benefits and barriers were associated with muscle strength. In the group without ascites, benefits were associated with cardiovascular risks and no association was observed with barriers to physical activity.

CONCLUSIONS

Perceived benefits and barriers to physical activity are associated with intrinsic factors such as the presence of ascites and cardiovascular risk in individuals with liver cirrhosis. The results of this study highlight key elements that must be considered for increasing physical activity in this population.

The impact of sarcopenia on oncologic abdominal wall reconstruction

BACKGROUND AND OBJECTIVES

Sarcopenia is an objective measure of patient frailty and is a predictor of adverse surgical outcomes. We hypothesized that sarcopenia is associated with increased surgical site occurrence (SSO) and hernia occurrences in patients undergoing oncologic abdominal wall reconstruction.

METHODS

Consecutive patients who underwent abdominal wall reconstruction (AWR) for an abdominal wall ablative defect at a single center from 2005 to 2015 were evaluated. The total psoas index (TPI) was used to define sarcopenia. The primary endpoint of the study was hernia occurrence; (SSO) was a secondary outcome measure.

RESULTS

Eighty-six patients met the inclusion criteria. Multivariate analysis demonstrated that sarcopenia increased the risk of hernia more than threefold, trending toward significance (OR = 3.3; 95% CI: 0.69-15.4; P = .13). Multivariate logistic regression demonstrated that preoperative radiotherapy (OR = 4.8, 95% CI: 1.4-16; P = .01) and obesity (OR = 4.9, 95% CI: 1.5-16.3; P =.009) were independent predictors of developing an SSO.

CONCLUSIONS

Sarcopenia, as defined by TPI, is correlated with hernia occurrence, but not SSO. These findings emphasize the importance of preoperative fitness and nutritional optimization and provide useful information for preoperative counseling and risk stratification.

Sarcopenia in Patients Undergoing Open Ventral Hernia Repair

Radiologic indicators of sarcopenia have been associated with adverse operative outcomes in some surgical populations. This study assesses the association of radiologic indicators of frailty with outcomes after open ventral hernia repair (OVHR). A prospective, institutional, herniaspecific database was queried for patients undergoing OVHR from 2007 to 2018 with preoperative CT. Psoas muscle cross-sectional area at L3 was measured and adjusted for height (skeletal muscle index (SMI)). L3 vertebral body density (L3 VBD) was measured. Demographics and outcomes were evaluated as related to SMI and L3 VBD. Of 1178 patients, 9.7 per cent of females and 15.8 per cent of males had sarcopenia and 11.6 per cent of females and 9.2 per cent of males had osteopenia. Neither sarcopenia nor osteopenia were associated with outcomes of wound infection, read-mission, reoperation, hernia recurrence, or major complications. When examined as continuous variables or by quartile, SMI and L3 VBD were not associated with adverse outcomes, including in subsets of male or female patients, the elderly, contaminated cases, and the obese. Radiologic markers of sarcopenia and osteopenia are not associated with adverse outcomes after OVHR. Further study should examine age or other potential predictors of outcomes in this patient population, such as independent status.

Sarcopenia as prognostic factor for survival after orthotopic liver transplantation

BACKGROUND AND AIM

Body composition has emerged as a prognostic factor for end-stage liver disease. We therefore investigated muscle mass, body fat and other clinical-pathological variables as predictors of posttransplant survival.

METHODS

A total of 368 patients, who underwent orthotopic liver transplantation (OLT) at our institution, were assessed prior to OLT and followed for a median of 9.0 years (range 2.0-10.0 years) after OLT. Psoas, erector spinae and the combined paraspinal muscle area, as well as the corresponding indices normalized by body-height squared, were quantified by a lumbar (L3) cross-sectional computed tomography. In addition, absolute body fat and bone density were estimated by the same computed tomography approach.

RESULTS

Paraspinal muscle index (PSMI) (hazard ratio 0.955, P = 0.039) and hepatitis C (hazard rati 1.498, P = 0.038) were independently associated with post-OLT mortality. In contrast, body fat and bone density did not significantly affect post-OLT outcome (P > 0.05). The PSMI also predicted one-year posttransplant mortality with a receiver operating characteristics-area under the curve of 0.671 [95% confidence interval (CI) 0.589-0.753, P < 0.001) in male patients and outperformed individual psoas and erector spinae muscle group assessments in this regard. In male patients, a defined PSMI cutoff (<18.41 cm/m) was identified as suitable determinant for sarcopenia and posttransplant one-year mortality. In female OLT-recipients, however, sarcopenia was not predictive for patient survival und a women-specific cutoff could not be derived from this study.

CONCLUSIONS

Taken together this analysis provides evidence, which PSMI is a relevant marker for muscle mass and that sarcopenia is an independent predictor of early post-OLT survival in male patients.

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.

Clinical impact of sarcopenia assessment in patients with hepatocellular carcinoma undergoing treatments

Changes in body composition are associated with poor outcomes in cancer patients including hepatocellular carcinoma (HCC). Sarcopenia, defined as the loss of skeletal muscle mass, quality and function, has been associated with a higher rate of complications and recurrences in patients with cirrhosis and HCC. The assessment of patient general status before HCC treatment, including the presence of sarcopenia, is a key-point for achieving therapy tolerability and to avoid short- and long-term complications leading to poor patients' survival. Thus, we aimed to review the current literature evaluating the role of sarcopenia assessment related to HCC treatments and to critically provide the clinicians with the most recent and valuable evidence. As a result, sarcopenia can be predictive of poor outcomes in patients undergoing liver resection, transplantation and systemic therapies, offering the chance to clinicians to improve the muscular status of these patients, especially those with high-grade sarcopenia at high risk of mortality. Further studies are needed to clarify the predictive value of sarcopenia in other HCC treatment settings and to evaluate its role as an additional staging tool for identifying the most appropriate treatment. Besides, interventional studies aiming at increasing the skeletal muscle mass for reducing complications and increasing the survival in patients with HCC are needed.

Serum Zinc Level Classification System: Usefulness in Patients with Liver Cirrhosis

Currently, the Japanese society of clinical nutrition (JSCN) defines serum zinc (Zn) level < 60 μg/dL as Zn deficiency and 60 μg/dL ≤ serum Zn level < 80 μg/dL as subclinical Zn deficiency, and 80 μg/dL ≤ serum Zn level < 130 μg/dL as normal Zn range. We aimed to elucidate the prognostic impact of this Zn classification system in patients with liver cirrhosis (LC) compared to the Child–Pugh classification and the albumin–bilirubin (ALBI) grading system (n = 441, median age = 66 years). The Akaike information criterion (AIC) with each evaluation method was tested in order to compare the overall survival (OS). The median serum Zn level was 65 μg/dL. There were 56 patients with normal Zn level, 227 with subclinical Zn deficiency and 158 with Zn deficiency. OS was well stratified among three groups of serum Zn level (p < 0.0001). The AIC value for survival by the Zn classification system was the lowest among three prognostic models (AIC: 518.99 in the Child–Pugh classification, 502.411 in ALBI grade and 482.762 in the Zn classification system). Multivariate analyses of factors associated with OS revealed that serum Zn classification by JSCN was an independent factor. In conclusion, the serum Zn classification proposed by JSCN appears to be helpful for estimating prognosis in LC patients.

Combined Albumin-Bilirubin Grade and Skeletal Muscle Mass as a Predictor in Liver Cirrhosis

We aimed to compare the prognostic impact among albumin-bilirubin (ALBI) grade, the Child-Pugh classification and our proposed combined ALBI grade and skeletal muscle mass (SMM) grading system in patients with liver cirrhosis (LC) (n = 468, 254 males and 214 females) using the Akaike information criterion (AIC) and time-dependent receiver operating characteristics (ROC) curve analysis. SMM was tested using bioimpedance analysis. Male subjects with skeletal muscle mass index (SMI) <7.0 cm²/m² and female subjects with SMI <5.7 cm²/m² were defined as having low SMM. Patients with ALBI grade 1, 2 and 3 were given 1, 2 and 3 points. Patients with and without low SMM were given 1 and 0 point, respectively. The sum of the point of ALBI (1, 2, or 3) and SMM (0 or 1) was defined as the ALBI-SMM grade. The value obtained with the AIC for survival by the ALBI-SMM grade was the lowest among three assessment methods (AIC: 513.418 in ALBI grade, 533.584 in Child-Pugh classification and 493.72 in ALBI-SMM grade). In time-dependent ROC analysis, all area under the ROCs of the ALBI-SMM grade in each time point were the highest among three assessment methods. In conclusion, the ALBI-SMM grading system can be helpful for LC patients.

Emerging awareness on the importance of skeletal muscle in liver diseases: time to dig deeper into mechanisms!

Skeletal muscle is a tissue that represents 30–40% of total body mass in healthy humans and contains up to 75% of total body proteins. It is thus the largest organ in non-obese subjects. The past few years have seen increasing awareness of the prognostic value of appreciating changes in skeletal muscle compartment in various chronic diseases. Hence, a low muscle mass, a low muscle function and muscle fatty infiltration are linked with poor outcomes in many pathological conditions. In particular, an affluent body of evidence links the severity, the complications and mortality of chronic liver disease (CLD) with skeletal muscle depletion. Yet it is still not clear whether low muscle mass is a cause, an aggravating factor, a consequence of the ongoing disease, or an epiphenomenon reflecting general alteration in the critically ill patient. The mechanisms by which the muscle compartment influences disease prognosis are still largely unknown. In addition, whether muscle alterations contribute to liver disease progression is an unanswered question. Here, we first review basic knowledge about muscle compartment to draw a conceptual framework for interpreting skeletal muscle alteration in CLD. We next describe recent literature on muscle wasting in cirrhosis and liver transplantation. We then discuss the implication of skeletal muscle compartment in non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH), focusing on plausible metabolic disruption in muscle compartment that might participate in NAFLD progression. Finally, we discuss shortcomings and challenges we need to address in the near future prior to designate the muscle compartment as a therapeutic target in CLD.

Patient and Caregiver Attitudes and Practices of Exercise in Candidates Listed for Liver Transplantation

BACKGROUND

Impaired physical capacity increases peri-liver transplant complications. Patient perceptions regarding exercise prior to transplantation are not known.

AIMS

This study aimed to assess patient and caregiver activity levels, perceptions of willingness to exercise, and of provider advice.

METHODS

Consecutive patients listed for liver transplant and caregivers presenting for routine outpatient visits were evaluated over a 3-month interval. Anonymous surveys adapted to patients and caregivers addressed the importance and safety of exercise, type and duration of exercise performed, barriers, willingness to wear a monitoring device, and perceived provider recommendations. Responses were logged on a Likert scale from 1 to 5.

RESULTS

Three hundred and sixty-eight responses were received. Most participants perceived exercise as important. Patients exercised three times per week for 30 min. Eighty percent endorsed walking (median response: 2-agree; IQR 1-2). Most did not jog, swim, cycle, or strength train. Fatigue, reported by 70%, was the major barrier (2, IQR 1-3). Over 90% of caregivers endorsed exercise as important (1-strongly agree, IQR 1-2) and encouraged exercise (median response 2, IQR 1-2). Over 60% of patients (median response 2, IQR 1-3) and caregivers (median response 2, IQR 2-3) felt providers encouraged exercise.

CONCLUSIONS

Patients and caregivers are willing to exercise to optimize physical fitness prior to liver transplantation.

Impact of pre-sarcopenia in sorafenib treatment for advanced hepatocellular carcinoma

Background

The present study aimed to investigate the impact of pre-sarcopenia on the prognosis of patients with advanced hepatocellular carcinoma (HCC) treated with sorafenib.

Methods

We enrolled 214 patients (71 ± 10 years old; 166 men and 48 women; 90% Child–Pugh grade A and 10% Child–Pugh grade B) treated with sorafenib in our hospital from July 2009 to August 2016. The muscle volume was measured from CT images just before sorafenib administration using software (SliceOmatic). Skeletal muscle mass index was calculated, and the presence of pre-sarcopenia was judged according to the standard (42 cm²/m² for men and 38 cm²/m² for women) proposed by the Japan Society of Hepatology.

Results

Pre-sarcopenia was found in 123 patients (57%). The overall survival (OS) in patients with pre-sarcopenia tended to be worse than in patients without pre-sarcopenia (median 252 vs. 284 days, respectively; p = 0.16). Multivariate Cox hazard analysis revealed a baseline serum albumin level of ≤3.5 g/dl [hazard ratio (HR) 1.9; p = 0.0006], a baseline alpha-fetoprotein(AFP) level of ≥100 ng/ml (HR 2.1; p = 0.002), presence of lesions in bilateral hepatic lobes (HR 1.7; p = 0.03), and presence of major portal vein invasion (HR 1.8; p = 0.01) to be independent prognostic factors. In the 68 patients who had three or more negative prognostic factors, the presence of pre-sarcopenia did not correlate with prognosis. Of the 146 patients who had two or less prognostic factors, OS was significantly worse in 84 patients (58%) with pre-sarcopenia than in 62 patients without pre-sarcopenia (median 417 vs. 562 days, respectively; p = 0.047), and Cox hazard analysis revealed pre-sarcopenia to be an important prognostic factor (HR 1.6; p = 0.047).

Conclusion

In sorafenib treatment for advanced HCC, pre-sarcopenia is a significant prognostic factor in patients with two or less negative prognostic factors, and could be the target of intervention to improve prognosis.

Determining the impact of sarcopenia on postoperative complications after ventral hernia repair

BACKGROUND

Postoperative complication following ventral hernia repair (VHR) is a major clinical and financial burden. Preoperative risk assessment is necessary to minimize adverse outcomes following VHR. This study examines the ability of an independent parameter to predict postoperative morbidity following VHR.

METHODS

A retrospective analysis of 58 patients who underwent VHR by component separation between January 2009 and December 2013 was performed. Preoperative abdominal CT scans were analyzed to assess sarcopenia. Sarcopenia was determined using the Hounsfield unit average calculation (HUAC), a measure of psoas muscle size and density. Sarcopenia was defined as an HUAC score of less than 19.6 HU calculated using receiver operating characteristic (ROC) analysis and the Youden index. Multivariate analysis was performed to analyze the association of sarcopenia and postoperative complications.

RESULTS

Preoperative sarcopenia was associated with an increased risk for postoperative complications (odds ratio [OR] = 5.3; p = 0.04). Preexisting gastrointestinal conditions such as ulcerative colitis or colon cancer were associated with an increased risk for postoperative complications (OR = 5.7; p = 0.05). A significantly higher rate of hernia recurrence (33.3% vs. 10.8% [p = 0.04]) and renal failure (19% vs. 2.7% [p = 0.03]) was noted in patients with sarcopenia when compared to patients without sarcopenia.

CONCLUSIONS

Sarcopenia is an independent risk factor for postoperative complications in patients who underwent VHR. Assessment of sarcopenia using the HUAC score provides an opportunity for the adjustment of perioperative care plans to minimize postoperative complication rates.

Nitric oxide treatment attenuates muscle atrophy during hind limb suspension in mice

Debilitating muscle-disuse atrophy in aging or obesity has huge socioeconomic impact. Since nitric oxide (NO) mediates muscle satellite cell activation and induces hypertrophy with exercise in old mice, we tested whether treatment with the NO donor, isosorbide dinitrate (ISDN), during hind limb suspension would reduce atrophy. Mice were suspended 18 days, with or without daily ISDN (66mg/kg). Muscles were examined for atrophy (weight, fiber diameter); regulatory changes in atrogin-1 (a negative regulator of muscle mass), myostatin (inhibits myogenesis), and satellite cell proliferation; and metabolic responses in myosin heavy chains (MyHCs), liver lipid, and hypothalamic gene expression. Suspension decreased muscle weight and weight relative to body weight between 25-55%, and gastrocnemius fiber diameter vs.

CONTROLS

In young-adult mice, ISDN attenuated atrophy by half or more. In quadriceps, ISDN completely prevented the suspension-induced rise in atrogin-1 and drop in myostatin precursor, and attenuated the changes in MyHCs 1 and 2b observed in unloaded muscles without treatment. Fatty liver in suspended young-adult mice was also reduced by ISDN; suspended young mice had higher hypothalamic expression of the orexigenic agouti-related protein, Agrp than controls. Notably, a suspension-induced drop in muscle satellite cell proliferation by 25-58% was completely prevented (young mice) or attenuated (halved, in young-adult mice) by ISDN. NO-donor treatment has potential to attenuate atrophy and metabolic changes, and prevent regulatory changes during disuse and offset/prevent wasting in age-related sarcopenia or space travel. Increases in precursor proliferation resulting from NO treatment would also amplify benefits of physical therapy and exercise.

Hyperammonemia and proteostasis in cirrhosis

PURPOSE OF REVIEW

Skeletal muscle loss or sarcopenia is a frequent complication of cirrhosis that adversely affects clinical outcomes. As skeletal muscle is the largest store of proteins in the body, proteostasis or protein homeostasis is required for maintenance of muscle mass. This review will focus on disordered skeletal muscle proteostasis in liver disease.

RECENT FINDINGS

Increased skeletal muscle uptake of ammonia initiates responses that result in disordered proteostasis including impaired protein synthesis and increased autophagy. The cellular response to the stress of hyperammonemia (hyperammonemic stress response, HASR) involves the coordinated action of diverse signaling pathways targeting the molecular mechanisms of regulation of protein synthesis. Transcriptional upregulation of myostatin, a TGFβ superfamily member, results in impaired mTORC1 signaling. Phosphorylation of the eukaryotic translation initiation factor 2α (eIF2α) also relates to decreased global protein synthesis rates and mTORC1 signaling. Ammonia also causes mitochondrial and bioenergetic dysfunction because of cataplerosis of α-ketoglutarate. Lowering ammonia, targeting components of HASR and regulating cellular amino acid levels can potentially restore proteostasis.

SUMMARY

Signaling via myostatin and eIF2α phosphorylation causes decreases in protein synthesis and mTORC1 activity with a parallel mitochondrial dysfunction and increased autophagy contributing to proteostasis perturbations during skeletal muscle hyperammonemia of liver disease.

Effect of branched-chain amino acid supplements on muscle strength and muscle mass in patients with liver cirrhosis

OBJECTIVE

The aim of this study was to assess the effect of branched-chain amino acid (BCAA) supplements on muscle strength and muscle mass in patients with liver cirrhosis.

PATIENTS AND METHODS

We carried out a single-center, prospective study of adult cirrhotic patients receiving nutrition therapy at Shonan Kamakura General Hospital. A 28-day pretreatment observation period was followed by a 24-week treatment period. Patients who fulfilled the treatment criteria received one package of oral BCAA supplement powder twice a day and the response was evaluated. A responder to BCAA in muscle strength and muscle mass was defined as a patient with an increased skeletal muscle mass index and hand grip assessed 24 weeks after drug treatment commenced.

RESULTS

Eighty-two patients fulfilled our criteria and completed the treatment. In terms of muscle strength, there were 59 (72.0%) responders to BCAA supplementation with a significant increase in hand grip from before treatment (22.2±6.3 kg) to after treatment (23.9±6.4 kg) (P<0.001). In terms of muscle mass, 36 (43.9%) patients responded to BCAA with a slight decrease in skeletal muscle mass index from before treatment (7.40±1.62) to after treatment (7.30±1.49) (P=0.333).

CONCLUSION

BCAA supplementation improved low muscle strength in patients with chronic liver disease, but did not increase muscle mass during the treatment period.

Elevated serum myostatin level is associated with worse survival in patients with liver cirrhosis

BACKGROUND

We aimed to elucidate the relationship between serum myostatin levels and other markers including skeletal muscle mass and to investigate the influence of serum myostatin levels on survival for patients with liver cirrhosis (LC).

METHODS

A total of 198 LC subjects were analysed in this study. Myostatin levels were measured using stored sera. We retrospectively investigated the relationship between myostatin level and other markers, and the influence of myostatin level on overall survival (OS). Assessment of skeletal muscle mass was performed using the psoas muscle index (PMI) on computed tomography images at baseline. PMI indicates the sum of bilateral psoas muscle mass calculated by hand tracing at the lumber three level on computed tomography images divided by height squared (cm² /m² ). The study cohort was divided into two groups based on the median myostatin value in each gender.

RESULTS

Our study cohort included 108 male and 90 female patients with a median age of 67.5 years. The median (range) myostatin level for male patients was 3419.6 pg/mL (578.4-12897.7 pg/mL), whereas that for female patients was 2662.4 pg/mL (710.4-8782.0 pg/mL) (P = 0.0024). Median (range) serum myostatin level for Child-Pugh A patients (n = 123) was 2726.0 pg/mL (578.4-12667.2 pg/mL), whereas that for Child-Pugh B or C patients (n = 75) was 3615.2 pg/mL (663.3-12897.7 pg/mL) (P = 0.0011). For the entire cohort, the 1-, 3-, 5-, and 7-year cumulative OS rates were 93.94%, 72.71%, 50.37%, and 38.47%, respectively, in the high-myostatin group and 96.97%, 83.27%, 73.60%, and 69.95%, respectively, in the low-myostatin group (P = 0.0001). After excluding hepatocellular carcinoma patients (at baseline) from our analysis (n = 158), the 1-, 3-, 5-, and 7-year cumulative OS rates were 96.0%, 77.93%, 52.97%, and 39.08%, respectively, in the high-myostatin group and 96.39%, 87.58%, 77.63%, and 73.24%, respectively, in the low-myostatin group (P = 0.0005). Higher age (P = 0.0111) and lower PMI (P < 0.0001) were identified as significant predictors of poorer OS in our multivariate analysis, while higher serum myostatin (P = 0.0855) tended to be a significant adverse predictor. In both genders, PMI, serum albumin, prothrombin time, and branched-chain amino acid to tyrosine ratio showed a significantly inverse correlation with myostatin levels, and serum ammonia levels showed a significantly positive correlation with myostatin levels.

CONCLUSIONS

Higher serum myostatin levels correlated with muscle mass loss, hyperammonemia, and impaired protein synthesis, as reflected by lower serum albumin levels and lower branched-chain amino acid to tyrosine ratio levels. High serum myostatin levels were also associated with a reduced OS rate in LC patients.

Comparing assessment tools for detecting undernutrition in patients with liver cirrhosis

BACKGROUND AND AIMS

Undernutrition in cirrhotic patients is often poorly recognised until late-stages. The current UK screening tool, the Malnutrition Universal Screening Tool, can miss undernutrition in patients with ascites/fluid retention. A 6-question Liver Disease Undernutrition Screening Tool (LDUST) has been developed in America.

METHODS

We sought to compare LDUST with MUST in the detection of undernutrition in 50 inpatients and 50 outpatients with liver cirrhosis in a secondary care setting. This was then validated by a dietitian assessment.

RESULTS

Similar patient demographics and liver disease aetiologies were found in the two cohorts. Mean Child-Pugh scores were higher for inpatients, 8.3 (SD 1.9) vs 5.9 (SD 1.2). LDUST detected undernutrition in 45/50 inpatients (90%) and 34/50 outpatients (68%). MUST scores ≥2 were present in 19/50 (38%) inpatients and 9/50 (18%) outpatients. In those with a MUST score <2, LDUST detected undernutrition in 26/31 (84%) inpatients and 27/41 (66%) outpatients. 26 inpatients had undernutrition using LDUST but had a MUST score <2, 20 (76%) of these were deemed to be undernourished by dietetics assessment. LDUST was mostly completed independently or with minimal assistance (80% inpatients, 100% outpatients), with mean completion times of 4 and 3 min for in- and outpatients respectively.

CONCLUSION

LDUST is a quick and easy screening tool, which appears better able than MUST to detect undernutrition in cirrhotic patients, including undernutrition missed by MUST. Importantly the tool was validated against dietitian assessments. The high rates of undernutrition among cirrhotic inpatients suggest that screening this cohort is unnecessary, and instead all should undergo dietitian review, with LDUST utilised in an outpatient setting.

A Comprehensive Review of Bioelectrical Impedance Analysis and Other Methods in the Assessment of Nutritional Status in Patients with Liver Cirrhosis

It is assumed that approximately 24–66% of patients with liver cirrhosis develop malnutrition. Numerous pathological processes lead to serious disorders of nutritional status in this group of patients. Malnutrition in the course of liver cirrhosis is associated with increased morbidity, complications, and low quality of life. Under these conditions, detection of malnutrition is of crucial importance. This review explores the complex mechanisms that lead to malnutrition in the course of liver cirrhosis and focuses on methods used in the assessment of nutritional status in cirrhotic patients. Among others, the role of bioelectrical impedance is highlighted. This noninvasive tool is promising and quite an accurate method of estimating body composition.

Comparison of Prognostic Impact between the Child-Pugh Score and Skeletal Muscle Mass for Patients with Liver Cirrhosis

AIMS

To investigate the influence of skeletal muscle mass index (SMI) as determined by bioimpedance analysis (BIA) (appendicular skeletal muscle mass/(height)²) on survival by comparing the Child-Pugh score in patients with liver cirrhosis (LC, n = 383, average age = 65.2 years).

PATIENTS AND METHODS

In terms of comparison of the effects of SMI and other markers on survival, we used time-dependent receiver operating characteristics (ROC) analysis.

RESULTS

The average SMI for male was 7.4 cm²/m² whereas that for female was 6.0 cm²/m² (p < 0.0001). As for the Child-Pugh score, five points were in the majority, both in males (51.7%, (106/205)) and females (44.9%, (80/178)). For both genders, the survival curve was well stratified according to SMI (p < 0.0001 for males and p = 0.0056 for females). In the multivariate analysis for survival, SMI and Child-Pugh scores were found to be significant both in males and females. In time-dependent ROC analyses, all area under the ROCs (AUROCs) for SMI in each time point were higher than those for Child-Pugh scores in males, while in females AUROCs for Child-Pugh scores at each time point were higher than those for SMI.

CONCLUSION

SMI using BIA can be helpful for predicting outcomes, at least in male LC patients.

Changes in skeletal muscle mass after endoscopic treatment in patients with esophageal varices

To the best of our knowledge, no available data with regard to changes in skeletal muscle mass for liver cirrhosis (LC) patients with esophageal varices (EVs) undergoing endoscopic therapy as a primary prophylaxis could exist. As endoscopic therapies, such as endoscopic injection sclerotherapy or endoscopic band ligation for EVs, accompany invasive procedure and patients with EVs receiving endoscopic therapies mostly rest in bed during hospitalization, clarifying these issues are clinically of importance. The purposes of this study were therefore to examine changes in skeletal muscle mass for LC patients with EVs undergoing endoscopic therapy as a primary prophylaxis and to identify pretreatment predictors which are associated with the amelioration in skeletal muscle mass. This is a subgroup analysis in our previous randomized controlled trial. A total of 51 LC patients with EVs were analyzed. Skeletal muscle mass was assessed using bioimpedance analysis (BIA). Skeletal muscle index (SMI) was defined as sum of skeletal muscle mass in body trunk and upper and lower extremities divided by height squared (cm/m) using data for BIA. We compared the changes in SMI at baseline and SMI at Day 50 after endoscopic treatment for EVs. Our study cohort included 33 males and 18 females with median (range) age of 62 (29-81) years. There were 31 patients with Child-Pugh A and 20 with Child-Pugh B. The median SMI for the entire cohort at baseline was 8.96 cm/m (range, 5.87-13.11 cm/m), while the median SMI for the entire cohort at Day 50 was 8.83 cm/m (range, 5.59-12.29 cm/m) (P = .9995). In baseline characteristics, prealbumin (P = .0477), branched-chain amino acid to tyrosine ratio (BTR) (P = .0056), and retinol-binding protein (P = .0296) in the increased SMI group (n = 15) were significantly higher than those in the nonincreased SMI group (n = 36). Multivariate analysis for the above 3 significant factors showed that only BTR was a significant prognostic pretreatment factor linked to the presence of increased SMI (P = .0235). In conclusion, pretreatment BTR level can be helpful for predicting increased SMI after endoscopic therapy as a primary prophylaxis for LC patients with EVs.

Implication of Psoas Muscle Index on Survival for Hepatocellular Carcinoma Undergoing Radiofrequency Ablation Therapy

Aims We aimed to retrospectively examine the impact of pretreatment psoas muscle index (PMI) as determined by computed tomography on survival for treatment naïve hepatocellular carcinoma (HCC) patients who underwent percutaneous radiofrequency ablation (RFA) therapy (n=182; 111 males and 71 females with median age of 70 years).

Patients and methods Optimal cut-off points of PMI in male and female were calculated by receiver operating characteristic analysis for survival. We investigated parameters associated with overall survival (OS) in the univariate and multivariate analyses.

Results The median follow-up period in this study was 4.28 years. For all cases, the 5-year cumulative OS rate after initial RFA was 69.2%. The median (range) value in PMI for male was 6.03 (1.63-9.90) cm²/m² whereas that for female was 4.06 (1.21-7.32) cm²/m². Maximum tumor size ranged from 0.7 cm to 3.5 cm (median, 1.5cm). There were 145 patients with single nodule and 37 with multiple nodules. The optimal cut-off point for PMI was 6.31 cm²/m² in male and 3.91 cm²/m² in female. The 5-year cumulative OS rates were 51.5% in the decreased PMI group (n=90) and 86.5% in the non-decreased PMI group (n=92) (P<0.0001). In patients with Child-Pugh A (n=137) and Child-Pugh B or C (n=45), similar results were obtained. In the multivariate analysis, presence of decreased PMI (P<0.0001), total bilirubin ≥1.2 mg/dl (P=0.0015) and des-γ-carboxy prothrombin ≥34 mAU/ml (P=0.0089) were found to be significant adverse predictors related to OS.

Conclusion PMI can be useful for predicting outcomes in HCC patients undergoing percutaneous RFA therapy.

Clinical utility of bioimpedance analysis in liver cirrhosis

BACKGROUND

The objective of the present study was to examine the impact of muscle mass depletion (MMD) as determined by data in bioimpedance analysis (BIA) in liver cirrhosis (LC) patients (n = 382, 204 in male and 178 in female) on survival and to validate the utility of cutoff values in BIA recommended from current recommendations.

METHODS

Muscle mass depletion was defined as patients with skeletal muscle mass index (SMI) using BIA <7.0 cm² /m² for male and <5.7 cm² /m² for female based on current recommendations. We retrospectively examined variables related to the presence of MMD using univariate and multivariate analyses and investigated the impact of MMD on survival.

RESULTS

A total of 135 patients (35.3%) had MMD. Subjects were predominantly Child-Pugh A (278/382, 72.8%). For the entire cohort, the 5-year cumulative survival rates were 59.8% in patients with MMD and 84.4% in patients without MMD (P < 0.0001). In the multivariate analysis for survival, MMD revealed to be a significant adverse predictor for survival and for most subgroup analyses, the differences between MMD group and non-MMD group in terms of survival reached significance.

CONCLUSION

Muscle mass measurement using BIA may be helpful for LC patients and current recommendations were well verified in our analysis.