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Padhi BK, Gandhi AP, Sandeep M, Shamim MA, De A, Rathi S, Singh S, Duseja A, Taneja S. Prevalence of Frailty and Its Impact on Mortality and Hospitalization in Patients With Cirrhosis: A Systematic Review and Meta-analysis. J Clin Exp Hepatol 2024; 14:101373. [PMID: 38495461 PMCID: PMC10940980 DOI: 10.1016/j.jceh.2024.101373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/18/2024] [Indexed: 03/19/2024] Open
Abstract
Background & aims Frailty in patients with cirrhosis is associated with increased morbidity and mortality. In this study, we aimed to determine the prevalence of frailty and its impact on mortality and hospitalization in patients with cirrhosis. Methods An elaborate search was undertaken in the databases "PubMed, Scopus, Web of Science, and Cochrane, and preprint servers", and an assessment of all published articles till 17 February 2023 was done. Studies that provided data on prevalence, mortality and hospitalization among frail patients with cirrhosis were included. The study characteristics and data on the prevalence, mortality, and hospitalization were extracted from included studies. The primary outcome was to estimate the pooled prevalence of frailty and determine its impact on mortality and hospitalization in patients with cirrhosis. Results Overall, 12 studies were included. Data on prevalence of frailty and mortality were available in 11 studies, while seven studies reported data on hospitalization. The analysis conducted among 6126 patients with cirrhosis revealed pooled prevalence of frailty to be 32% (95% confidence interval [CI], 24-41). A total of 540 events of death revealed a pooled mortality rate of 29% (95% CI, 19-41). Six-month and twelve-month pooled estimates of mortality were found to be 24% (95% CI, 17-33) and 33% (95% CI, 23-45), respectively. The pooled hospitalization rate among the seven studies was 43% (95% CI, 21-68). Conclusion The prevalence of frailty in patients with cirrhosis is high, leading to poor outcomes. Frailty assessment should become an integral part of cirrhosis evaluation. Registry and registration number of study PROSPERO 2022 CRD42022377507.
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Affiliation(s)
- Bijaya K. Padhi
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Aravind P. Gandhi
- Department of Community Medicine, All India Institute of Medical Sciences, Nagpur, India
| | | | - Muhammad A. Shamim
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, India
| | - Arka De
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sahaj Rathi
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Surender Singh
- Department of Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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Yuan C, Li W, Liu J, Li J. Frailty and transplant-free survival of patients with liver cirrhosis: A meta-analysis. PLoS One 2024; 19:e0302836. [PMID: 38722913 PMCID: PMC11081249 DOI: 10.1371/journal.pone.0302836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/12/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Frailty is a common condition among patients with liver cirrhosis. Nonetheless, its role in predicting liver transplant-free survival (TFS) remains unclear. AIM This systematic review and meta-analysis were conducted to elucidate the relationship between frailty and TFS in patients with cirrhosis. METHODS Cohort studies addressing the objective of this meta-analysis were extracted from PubMed, Embase, and Web of Science databases. Between-study heterogeneity was assessed with the Cochrane Q test, and the I^2 statistic was estimated. Random-effect models, considering potential heterogeneity, were employed to combine the results. RESULTS The meta-analysis encompassed 17 cohort studies involving 6273 patients with cirrhosis, of whom 1983 (31.6%) were classified as frail at baseline. The follow-up periods in the included studies ranged from 3 to 29 months, with an average duration of 11.5 months. The analysis revealed that frailty was significantly associated with a poor TFS (risk ratio [RR]: 2.07, 95% confidence interval: 1.72 to 2.50, p<0.001; I2 = 51%). Sensitivity analyses that sequentially omitted one dataset consistently supported these findings (RR: 1.95 to 2.17, p<0.05 in all cases). Subgroup analyses based on variables such as study design, mean age of patients, baseline Model for End-Stage Liver Disease score, tool used for frailty evaluation, follow-up duration, and study quality score also yielded congruent results. CONCLUSIONS The evidence suggests that frailty may be an independent risk factor for poor TFS in patients with liver cirrhosis, thus emphasizing the importance of early identification and management of frailty in this population.
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Affiliation(s)
- Chunhui Yuan
- Department of Gastroenterology, Changsha Fourth Hospital, Changsha, Hunan Province, China
| | - Weihua Li
- Department of Gastroenterology, Changsha Fourth Hospital, Changsha, Hunan Province, China
| | - Jie Liu
- Department of Gastroenterology, Changsha Fourth Hospital, Changsha, Hunan Province, China
| | - Jianguo Li
- Department of Gastroenterology, Changsha Fourth Hospital, Changsha, Hunan Province, China
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Xie R, Jing X, Yang C. The prevalence and characteristics of frailty in cirrhosis patients: a meta-analysis and systematic review. Front Med (Lausanne) 2024; 11:1353406. [PMID: 38745743 PMCID: PMC11092890 DOI: 10.3389/fmed.2024.1353406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/08/2024] [Indexed: 05/16/2024] Open
Abstract
Objectives This study aimed to assess the prevalence of frailty in cirrhosis patients and the distribution of age, sex, and body mass index (BMI) in cirrhotic patients with frailty. Methods We performed a thorough literature search using PubMed, Embase, Web of Science, and the Cochrane Library from inception to 29 February 2024. The estimated prevalence with a 95% confidence interval (CI) was calculated with a random effect model. Subgroup analysis and sensitivity analysis were performed to assess the heterogeneity and characterize the distribution of age, sex, and body mass index (BMI) in cirrhotic patients. Publication bias was assessed by the funnel plot, Begg's test, and Egger's test. Results The 16 included studies, which were all observational, reported a prevalence of frailty in 8,406 cirrhosis patients ranging from 9 to 65%, and the overall estimated prevalence was 27% (95% CI: 21-33%; I2 = 97.7%, P < 0.001). This meta-analysis indicated that the estimated prevalence of frailty in cirrhosis patients was high, and compared to the non-frail cohort, the frail cohort tended to have a higher mean age, with a mean age of 63.3 (95% CI: 59.9, 66.7; Z = 36.48; P < 0.001), and a larger proportion of male patients with worse liver function, with a mean of 73.5% (95% CI: 71.4, 75.5%; Z = 7.65; P < 0.001), ND in the frail cohort, 54.8% (95% CI: 43.1, 66.5%; P < 0.001) and 23.4% (95% CI: 13.2, 33.7%; P < 0.001) were classified into Child-Pugh B and C, respectively. Meanwhile, the patients in the non-frail cohort are more likely to have a higher BMI, with a mean of 28.4 (95% CI: 24.1, 32.7; Z = 13.07; P < 0.001). Conclusion The current study suggests that cirrhosis patients have a high prevalence of frailty. Compared with the non-frail cohort, the frail patients tend to be male, older, and have a lower BMI with worse liver function.
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Affiliation(s)
- Ruiyu Xie
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Center for Digestive Diseases, Shijiazhuang, Hebei, China
| | - Xiaotong Jing
- Department of Hematology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Chuanjie Yang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Center for Digestive Diseases, Shijiazhuang, Hebei, China
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Fudeyasu K, Ushio K, Nomura T, Kawae T, Iwaki D, Nakashima Y, Nagao A, Hiramatsu A, Murakami E, Oka S, Mikami Y. Advanced liver fibrosis is associated with decreased gait speed in older patients with chronic liver disease. Sci Rep 2024; 14:6809. [PMID: 38514842 PMCID: PMC10957869 DOI: 10.1038/s41598-024-57342-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/18/2024] [Indexed: 03/23/2024] Open
Abstract
This study investigated whether the progression of liver fibrosis affects the prevalence of sarcopenia and incidence of decreased gait speed in older patients with chronic liver disease (CLD). Patients with CLD aged ≥ 60 years were classified into low, intermediate, and high fibrosis 4 (FIB-4) index groups according to the degree of liver fibrosis. The prevalence of sarcopenia and incidence of decreased gait speed (< 1.0 m/s) were compared among the three groups. Logistic regression analysis was performed to investigate factors affecting the risk of decreased gait speed. No significant difference was observed in the prevalence of sarcopenia among the three groups, but the incidence of decreased gait speed significantly differed (p = 0.029). When analyzed individually, a significant difference in decreased gait speed incidence was observed between the high and low FIB-4 index groups (p = 0.014). In logistic regression analysis, the progression of liver fibrosis (odds ratio: 1.32, 95% confidence interval: 1.13-1.55) and lower extremity muscle strength (LEMS) (odds ratio: 0.92, 95% confidence interval: 0.88-0.97) were significantly associated with decreased gait speed. As liver fibrosis progresses in older patients with CLD, it becomes important to focus on not only skeletal muscle mass and grip strength, but also gait speed and LEMS.
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Affiliation(s)
- Kenichi Fudeyasu
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Kai Ushio
- Department of Rehabilitation Medicine, Hiroshima University Hospital, Hiroshima, Japan.
| | - Takuo Nomura
- Department of Physical Therapy, Faculty of Rehabilitation, Kansai Medical University, Osaka, Japan
| | - Toshihiro Kawae
- Department of Physical Therapy, Makuhari Human Care Faculty, Tohto University, Chiba, Japan
| | - Daisuke Iwaki
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuki Nakashima
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Akiko Nagao
- Division of Nutrition Management, Hiroshima University Hospital, Hiroshima, Japan
| | - Akira Hiramatsu
- Department of Gastroenterology, KKR Hiroshima Memorial Hospital, Hiroshima, Japan
| | - Eisuke Murakami
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yukio Mikami
- Department of Rehabilitation Medicine, Hiroshima University Hospital, Hiroshima, Japan
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Hui Y, Wang H, Guo G, Yang W, Wang X, Cui B, Fan X, Sun C. Health-related quality of life and frailty in liver cirrhosis. BMJ Support Palliat Care 2024:spcare-2024-004839. [PMID: 38471790 DOI: 10.1136/spcare-2024-004839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND AND OBJECTIVES There is limited evidence concerning the predictive value of health-related quality of life (HRQoL) on the presence of frailty in the context of cirrhosis. We aimed to elucidate the relationship between HRQoL and multidimensional frailty and to determine which HRQoL dimension independently impacted frail phenotype in our established cohort. METHODS This was a prospective observational study by consecutively enrolling 355 patients with cirrhotic with decompensated signs in China. The HRQoL and frail phenotype were evaluated by the EuroQol-5D (EQ-5D) Questionnaire and Frailty Index, respectively. The relationship between EQ-5D utility index, as well as respective EQ-5D dimension, and Frailty Index was analysed according to the multiple linear regression analyses. RESULTS More than half of the patients (56.3%) reported problems in any dimension of the EQ-5D, suggestive of impaired HRQoL. Moreover, the proportion of patients experiencing some/extreme problems significantly increased across all five dimensions (all p<0.001) in correspondence to transition from the robust to frail phenotype. Multiple linear regression analyses demonstrated that age, ascites and hepatic encephalopathy were positively associated with Frailty Index, while EQ-5D utility index (standardised β coefficient= -0.442, p<0.001) negatively associated with Frailty Index. Notably, usual activities, self-care and mobility were the most influencing predictors associated with frailty. CONCLUSIONS Our results support a rapid HRQoL assessment via EQ-5D may assist in predicting multidimensional frailty, and usual activities, self-care and mobility tend to be remediable targets while taking their effect on frail phenotype into consideration among patients with cirrhosis.
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Affiliation(s)
- Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Han Wang
- Tianjin Hospital, Hexi District, Tianjin, China
| | - Gaoyue Guo
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Wanting Yang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Xiaoyu Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Binxin Cui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Xiaofei Fan
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
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Okada T, Tanaka S, Shinkawa H, Ohira G, Kinoshita M, Amano R, Kimura K, Nishio K, Tauchi J, Uchida-Kobayashi S, Fujii H, Ishizawa T. Impact of frailty on long-term outcomes after liver resection for hepatocellular carcinoma in elderly patients: A prospective study. Asian J Surg 2024; 47:147-153. [PMID: 37302885 DOI: 10.1016/j.asjsur.2023.05.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/14/2023] [Accepted: 05/26/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND sFrailty affects short-term outcomes after liver resection in elderly patients. However, frailty's effects on long-term outcomes after liver resection in elderly patients with hepatocellular carcinoma (HCC) are unknown. METHODS This prospective, single-center study included 81 independently living patients aged ≥65 years scheduled to undergo liver resection for initial HCC. Frailty was evaluated according to the Kihon Checklist, a phenotypic frailty index." We investigated and compared postoperative long-term outcomes after liver resection between patients with and without frailty. RESULTS Of the 81 patients, 25 (30.9%) were frail. The proportion of patients with cirrhosis, high serum alpha-fetoprotein level (≥200 ng/mL), and poorly differentiated HCC was higher in the frail group than in the nonfrail group (n = 56). Among the patients with postoperative recurrence, the incidence of extrahepatic recurrence was higher in the frail group than in the nonfrail group (30.8% vs. 3.6%, P = 0.028). Moreover, the proportion of patients who underwent repeat liver resection and ablation for recurrence who met the Milan criteria tended to be lower in the frail group than in the nonfrail group. Although there was no difference in disease-free survival between the two groups, the overall survival rate in the frail group was significantly worse than that in the nonfrail group (5-year overall survival: 42.7% vs. 77.2%, P = 0.005). Results of the multivariate analysis indicated that frailty and blood loss were independent prognostic factors for postoperative survival. CONCLUSION Frailty is associated with unfavorable long-term outcomes after liver resection in elderly patients with HCC.
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Affiliation(s)
- Takuma Okada
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shogo Tanaka
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan.
| | - Hiroji Shinkawa
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Go Ohira
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Masahiko Kinoshita
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Ryosuke Amano
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Kenjiro Kimura
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Kohei Nishio
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Jun Tauchi
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Sawako Uchida-Kobayashi
- Department of Hepatology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hiromichi Fujii
- Department of Intensive Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Takeaki Ishizawa
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Mishra S, Premkumar M. Nutritional Management of a Liver Transplant Candidate. J Clin Exp Hepatol 2023; 13:878-894. [PMID: 37693267 PMCID: PMC10483011 DOI: 10.1016/j.jceh.2023.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/28/2023] [Indexed: 09/12/2023] Open
Abstract
Nearly two-thirds of patients with cirrhosis suffer from malnutrition resulting from multiple contributory factors such as poor intake, accelerated starvation, catabolic milieu, and anabolic resistance. Nutritional assessment and optimization are integral to adequate management of a liver transplant (LT) candidate. A detailed nutritional assessment should be done at baseline in all potential transplant candidates with periodic reassessments. Sarcopenia is defined as a reduction in muscle mass, function, and/or performance. Skeletal muscle index at 3rd lumbar vertebra determined by computed tomography is the most objective tool to assess muscle mass. Hand-grip strength and gait speed are simple tools to gauge muscle strength and performance, respectively. Sarcopenia, sarcopenic obesity, and myosteatosis portend poor outcomes. Sarcopenia contributes greatly to frailty, which is a syndrome of reduced physiological reserve and impaired response to stressors. Dietary interventions must ensure adequate calorie (35-40 kcal/kg/day) and protein (1.2-1.5 gm/kg/day) intake via multiple frequent meals and late-evening calorie-dense snack. Micronutrient supplementation is essential, keeping in mind the etiology of cirrhosis. Individualized, gradually up-titrated exercise prescription consisting of both aerobic and resistance training of 150 min/week is advisable after appropriate risk assessment. Early initiation of enteral nutrition within 12-24 h of LT is recommended. Data with respect to immune-nutrition, monomeric formulas, and hormone replacement remain conflicting at present. A multidisciplinary team comprising of hepatologists, transplant surgeons, intensivists, dieticians, and physiotherapists is vital to improve overall nutrition and outcomes in this vulnerable group.
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Affiliation(s)
- Saurabh Mishra
- Department of Gastroenterology and Hepatology, Paras Health, Sector-22, Panchkula, Haryana, 134109, India
| | - Madhumita Premkumar
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India
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Deng Y, Hui Y, Cui B, Xie W, Sun C. Accumulating awareness on the clinical significance and relevance of frailty in cirrhosis: Time to dig deeper into mechanistic basis! Liver Int 2023; 43:1629-1643. [PMID: 37288711 DOI: 10.1111/liv.15639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 04/03/2023] [Accepted: 05/25/2023] [Indexed: 06/09/2023]
Abstract
Frailty corresponds to an emerging construct in the hepatology which is originally introduced as a validated geriatric syndrome regarding increased vulnerability to pathophysiological stressors. As for patients with cirrhosis, the presence of frailty is indicative of debilitating conditions that subjects are prone to deleterious acute insults and have difficulties to restore even if the underlying liver function partially returned to normal levels. Since this conceptual development, a variety of tools assessing frailty have been proposed and evaluated in the context of cirrhosis. A recent performance-based metric for frailty, designated as Liver Frailty Index, has broadly been applied in patients with cirrhosis and exhibited acceptable predictive ability in relation to disease progression, mortality and hospitalization. However, those functional tests measuring frailty may be impossible to perform in circumstance that patients are critically ill or undergoing detrimental events. An interesting modality indicates the use of alternative tests to evaluate frailty, which may be more adaptable and of choice for specific subgroups. The interrelation between frailty and various cirrhosis-associated pathological entities is of clinical importance and implication. Noticeably, it is imperative to clarify these complex linkages to highlight novel therapeutic targets or interventional endpoints. The efficient and effective management of frailty is still challenging, but many attempts have been made to overcome barriers of affordability and availability. Some clinical trials on small scale revealed that home-based exercise and individualized nutrition therapy show benefits in patients with cirrhosis, and high adherence to the treatment regimen may direct better efficacy and performance.
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Affiliation(s)
- You Deng
- Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Binxin Cui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Wen Xie
- Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
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Philips CA, Kedarisetty CK. Palliative Care for Patients with End-Stage Liver Disease. J Clin Exp Hepatol 2023; 13:319-328. [PMID: 36950499 PMCID: PMC10025682 DOI: 10.1016/j.jceh.2022.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/07/2022] [Indexed: 02/17/2023] Open
Abstract
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.
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Key Words
- ACLF
- ACLF, acute-on-chronic liver failure
- CPT, Child–Pugh–Turcotte
- ESLD, end-stage liver disease
- HE, hepatic encephalopathy
- INR, international normalized ratio
- LSM, liver stiffness measurement
- LT, liver transplantation
- MELD, model for end stage liver disease
- PC, palliative care
- TE, transient elastography
- TIPS, transjugular intrahepatic portosystemic shunt
- ascites
- cirrhosis
- end of life care
- hepatic encephalopathy
- hyponatremia
- portal hypertension
- sepsis
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Affiliation(s)
- Cyriac A. Philips
- Department of Clinical and Translational Hepatology and the Monarch Liver Laboratory, Rajagiri Hospital, Aluva, Kerala, India
| | - Chandan K. Kedarisetty
- Department of Hepatology and Liver Transplantation, Gleneagles Global Hospital, Hyderabad, India
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Xiong J, Tian Y. Evaluating sarcopenia in patients with cirrhosis: The role of muscle function. J Hepatol 2022; 77:564-565. [PMID: 35351521 DOI: 10.1016/j.jhep.2022.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Jianping Xiong
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yantao Tian
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
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Abstract
PURPOSE OF REVIEW Ageing, the accrual of molecular and cellular damage over a lifetime confers progressive physiologic dysfunction of bodily systems, leaving the body in a heightened state of vulnerability to biophysical and psychosocial stressors. The inflection point is frailty which easily leads to disability and death. Interstitial lung disease (ILD) creates biophysical and psychosocial stresses difficult for even optimally fit patients to cope with. With evolving ILD treatment pathways, people with ILD are living longer. RECENT FINDINGS ILD and ageing are bi-directionally influential: ILD, its treatments, complications, and collateral systemic extra-pulmonary damage (hypoxic and oxidative stress) wear on the ageing person and ageing impacts a person's tolerance of ILD. ILD extent may proportionally accelerate age-related vulnerabilities. ILD related to inflammatory systemic diseases, e.g. connective tissue diseases or sarcoidosis, exert an even more complex biophysical impact on the body. SUMMARY The present review stresses goals of preventing frailty in ILD and preserving general health and well being of people living with ILD of any age, from time of diagnosis and as they age. The development of a prediction score is proposed to classify those at risk of frailty and guide interventions that preserve successful ageing for all levels of ILD severity. VIDEO ABSTRACT http://links.lww.com/COPM/A32.
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Hospital Frailty Risk Score Is Independently Associated with Mortality and Encephalopathy in Hospitalized Patients with Hepatocellular Carcinoma. Biomedicines 2021; 9:biomedicines9111693. [PMID: 34829921 PMCID: PMC8615905 DOI: 10.3390/biomedicines9111693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 12/27/2022] Open
Abstract
Frailty represents a state of vulnerability to multiple internal physiologic factors, as well as external pressures, and has been associated with clinical outcomes. We aim to understand the impact of frailty on patients admitted with hepatocellular carcinoma (HCC) by using the validated Hospital Frailty Risk Score, which is implemented in several hospitals worldwide. We conducted a nation-wide retrospective cohort study to determine the effect of frailty on the risk of in-patient mortality, hepatic encephalopathy, length of stay and cost. Frailty was associated with a 4.5-fold increased risk of mortality and a 2.3-fold increased risk of hepatic encephalopathy. Adjusted Cox regression showed that frailty was correlated with increased risk of in-patient mortality (hazard ratio: 2.3, 95% CI 1.9-2.8, p < 0.001). Frail HCC patients had longer hospital stay (median 5 days) vs. non-frail HCC patients (median 3 days). Additionally, frail patients had higher total costs of hospitalization ($40,875) compared with non-frail patients ($31,667). Frailty is an independent predictor of hepatic encephalopathy and in-patient mortality. Frailty is a surrogate marker of hospital length of stay and cost.
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Ayorinde T, Panayotova G, Sharma A, Lunsford KE. Clinical and biomarker assessment of frailty in liver transplantation. Curr Opin Organ Transplant 2021; 26:488-497. [PMID: 34343156 PMCID: PMC8446327 DOI: 10.1097/mot.0000000000000911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Liver cirrhosis results in progressive decline, or frailty, which leads to poor outcomes and decreased survival. Multiple biomarkers and clinical assessment tools for quantifying frailty in liver transplant candidates exist, but a universal scoring protocol is lacking. Criteria vary between studies and correlation with patient outcome is not always clear. This review aims to summarize the pertinent biomarkers and assessment tools of frailty in cirrhosis. RECENT FINDINGS As cirrhosis progresses, the resultant 'frailty' is an inseparable independent predictor of pre and posttransplant mortality. Pro-inflammatory, neuroendocrine, and adipokine factors are dysregulated - leading to paradoxical anorexia and downregulation of orexigenic signals. The resulting catabolic utilization of amino and fatty acids leads to progressive malnutrition and sarcopenia. Both functional and imaging criteria define sarcopenia in cirrhotic patients, and degree of debilitation correlates with mortality. Liver-disease-specific frailty biomarkers and scoring tools are optimal to assess physical dysfunction in cirrhotics to promote early diagnosis and intervention. SUMMARY Liver cirrhosis and resulting frailty are progressive and portend a poor patient prognosis. A comprehensive, validated algorithm for detecting and quantifying frailty specific to liver disease would allow for standardization and facile application in the clinical setting. Early diagnosis is key for timely intervention and improved patient outcomes.
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Affiliation(s)
- Tumininu Ayorinde
- Division of Transplant and HPB Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Guergana Panayotova
- Division of Transplant and HPB Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Aanchal Sharma
- Division of Transplant and HPB Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Keri E. Lunsford
- Division of Transplant and HPB Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
- Center for Immunity and Inflammation, Institute for Infectious and Inflammatory Diseases, Rutgers New Jersey Medical School, Newark, NJ
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Lattanzi B, Bruni A, Di Cola S, Molfino A, De Santis A, Muscaritoli M, Merli M. The Effects of 12-Week Beta-Hydroxy-Beta-Methylbutyrate Supplementation in Patients with Liver Cirrhosis: Results from a Randomized Controlled Single-Blind Pilot Study. Nutrients 2021; 13:nu13072296. [PMID: 34371806 PMCID: PMC8308449 DOI: 10.3390/nu13072296] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/28/2021] [Accepted: 06/28/2021] [Indexed: 12/12/2022] Open
Abstract
Background and Aim: Sarcopenia is considered an important risk factor for morbidity and mortality in liver cirrhosis. Beta-hydroxy-beta-methylbutyrate (HMB) has the potential to increase muscle mass and performance by stimulating protein synthesis and reducing muscle catabolism. The present study aimed at evaluating the effect of HMB supplementation on muscle mass and function in patients with liver cirrhosis. Changes in frailty during the study were also estimated, and the safety of HMB supplementation was verified. Methods: This is a randomized, single-blind, placebo-controlled pilot trial. Twenty-four patients (14 HMB and 10 placebo) affected by liver cirrhosis were enrolled in the study. Each patient received dedicated counseling, which included nutrition and physical activity recommendations for chronic liver disease patients. Patients were randomized to receive 3 g/day of HMB or placebo (sorbitol powder) for 12 consecutive weeks. A diet interview, anthropometry, electrical bioimpedance analysis (BIA), quadriceps ultrasound, physical performance battery, Liver Frailty Index (LFI), and cognitive tests were completed at enrolment (T0), at 12 weeks (T1), and 24 weeks after enrolment (T2). Results: At baseline, the two groups were similar in demography, severity of liver disease, muscle mass, muscle function, and cognitive tests. LFI at baseline was higher in patients in the HMB group vs. those in the placebo group (4.1 ± 0.4 vs. 3.4 ± 0.6, p < 0.01). After treatment, a statistically significant increase in muscle function was seen in the HMB group (chair stand test: 14.2 ± 5 s vs. 11.7 ± 2.6 s, p < 0.05; six-minute walk test: 361.8 ± 68 m vs. 409.4 ± 58 m, p < 0.05). Quadriceps muscle mass measured by ultrasound also increased (4.9 ± 1.8 vs. 5.4 ± 1.8 mm, p < 0.05) after HMB, while LFI decreased (4.1 ± 0.4 vs. 3.7 ± 0.4, p < 0.05). HMB was well tolerated by patients, and no adverse events were documented. Conclusions: Our study suggests the efficacy of 12-week beta-hydroxy-beta-methylbutyrate supplementation in promoting improvements in muscle performance in compensated cirrhotic patients. LFI was also ameliorated. Further studies with a greater number of patients are required to reinforce this hypothesis.
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Affiliation(s)
- Barbara Lattanzi
- Gastroenterology, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (B.L.); (A.B.); (S.D.C.); (A.D.S.)
| | - Angelo Bruni
- Gastroenterology, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (B.L.); (A.B.); (S.D.C.); (A.D.S.)
| | - Simone Di Cola
- Gastroenterology, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (B.L.); (A.B.); (S.D.C.); (A.D.S.)
| | - Alessio Molfino
- Internal Medicine, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (A.M.); (M.M.)
| | - Adriano De Santis
- Gastroenterology, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (B.L.); (A.B.); (S.D.C.); (A.D.S.)
| | - Maurizio Muscaritoli
- Internal Medicine, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (A.M.); (M.M.)
| | - Manuela Merli
- Gastroenterology, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (B.L.); (A.B.); (S.D.C.); (A.D.S.)
- Correspondence: ; Tel.: +39-(06)-49972001
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Wang X, Feng H, Hui Y, Zhao T, Mao L, Fan X, Cui B, Lin L, Zhang J, Wang B, Yu Q, Zhao X, Sun C. A predictive nomogram incorporating gait speed for all-cause mortality in hospitalized cirrhotics. Postgrad Med 2021; 133:680-687. [PMID: 34029498 DOI: 10.1080/00325481.2021.1934494] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES No tailored model incorporating physical frailty for 2-year mortality in cirrhosis is available for practitioners in general practice. Thus we aimed to develop a model based on laboratory results and physical frailty allowing clinicians for stratifying cirrhotics by using individual estimate. METHODS One hundred and thirteen cases were assigned to the primary cohort, and all other 76 patients were regarded as the validation cohort. Multivariate Cox regression was performed, and a nomogram including five-meter gait speed (5MGS) were generated. The performance of the proposed model was assessed by C-index, calibration curve, and decision curve analysis (DCA). RESULTS On multivariate analysis, the Model for End-Stage Liver Disease-Sodium, albumin and 5MGS were independent predictors for 2-year mortality in cirrhosis. A nomogram incorporating all these parameters achieved a C-index of 0.804 (95%CI, 0.731-0.877). The calibration curve implied optimal correspondence between the predicted survival and actual outcomes. Our model is useful in the clinical settings based on DCA. Similar results were observed in the validation cohort with a C-index of 0.796 (95%CI, 0.689-0.899). Moreover, 5MGS, as a surrogate of physical performance, significantly correlated with multiple domains of general frailty according to Frailty Index (our published data), including instrumental activities of daily living, self-reported health, social activity and falls. CONCLUSION In conclusion, the nomogram incorporating 5MGS may represent an individualized tool for predicting mortality in cirrhosis for primary care physicians.
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Affiliation(s)
- Xiaoyu Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongjuan Feng
- Department of Nutriology, Tianjin Third Central Hospital, Tianjin, China
| | - Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Tianming Zhao
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Lihong Mao
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaofei Fan
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Binxin Cui
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Lin Lin
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Jie Zhang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Bangmao Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Qingxiang Yu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Xingliang Zhao
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
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Son SW, Song DS, Chang UI, Yang JM. Definition of Sarcopenia in Chronic Liver Disease. Life (Basel) 2021; 11:349. [PMID: 33923561 PMCID: PMC8074027 DOI: 10.3390/life11040349] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 02/07/2023] Open
Abstract
Sarcopenia, which is characterized by decline in muscle mass, muscle strength, and physical performance, is common in patients with chronic liver disease (CLD) and is associated with poor clinical outcomes. Several consensus definitions for community-dwelling elderly people have been proposed, and these recommend the use of various tools and tests to assess muscle properties and performance. These measurement tools have also been applied in patients with CLD and have been useful for predicting prognosis. However, sarcopenia and its diagnostic criteria specific to patients with CLD have not yet been clearly defined. In addition, fluid retention and body composition should be considered when sarcopenia is assessed in patients with CLD. This review aims to introduce definitions of sarcopenia and diagnostic tools used in patients with CLD.
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Affiliation(s)
| | - Do Seon Song
- Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.W.S.); (U.I.C.); (J.M.Y.)
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