Handgrip Strength as an Important Bed Side Tool to Assess Malnutrition in Patient with Liver Disease

Cutoff points for handgrip strength in patients with liver cirrhosis: a multicenter study

OBJECTIVES

This study aimed to define handgrip strength (HGS) cutoff points to predict 1-year mortality in adult patients with liver cirrhosis.

METHODS

This is an analysis of cohort databases from four reference centers in Brazil. Inpatients or outpatients with cirrhosis and aged ≥18 years were included. The best cutoff values of HGS (highest value from three attempts with the non-dominant hand) for predicting 1-year mortality, stratified by sex and age, were established based on the sensitivity and specificity analyses. Adjusted Cox regression models were used to test the predictive value of low HGS.

RESULTS

The study included 724 patients with cirrhosis, with a median age of 57.0 years (IQR: 50.0-63.0), 66.4% (n = 481) male. Most patients had alcoholic cirrhosis (n = 281; 38.8%), 400 (55.3%) were classified as Child-Pugh B or C, and 134 (18.5%) patients died after 1-year. The HGS cutoffs were ≤33 kgf and ≤12 kgf for men and women aged <60 years, respectively, and ≤22 kgf and ≤10 kgf for older men and women, respectively (sensitivity: 70.9%; specificity: 61.2%). Low HGS was associated with a 2.5-fold increase in the risk of 1-year mortality.

CONCLUSION

These cutoff points could be used to identify patients with a higher mortality risk.

Assessment of sub-maximal aerobic capacity in North African patients with chronic hepatitis B: a pilot case-control study

Background

Studies assessing sub-maximal aerobic capacity in non-cirrhotic chronic hepatitis B (CHB) patients are scarce. This study aimed to evaluate sub-maximal aerobic capacity in CHB patients compared to apparently healthy participants (control-group (CG)).

Methods

A 6-min walk test (6MWT) was performed. The 6-min walk distance (6MWD) was recorded, along with heart-rate (HR), oxy-hemoglobin saturation (SpO 2), blood-pressure, and dyspnea ( ie ; visual analogue scale) at rest (Rest) and at the end (End) of the 6MWT. Additionally, the 6-min walk work (6MWW), and estimated cardiorespiratory and muscular chain age were calculated. Signs of physical intolerance were determined including abnormal 6MWD ( ie ; 6MWD < lower limit of normal), chronotropic insufficiency (ie ; HREnd < 60% of maximal predicted HR (MPHR)), high dyspnea ( ie ; dyspneaEnd > 5), and desaturation ( ie ; drop in SpO 2 > 5 points).

Results

Compared to the CG (n=28), the CHB-group (n=26) exhibited significantly lower 6MWD by 61 meters (8%), lower 6MWW by 10%, and lower HR End by 21% (when expressed in bpm) and 17% (when expressed in %MPHR). The CHB-group, compared to the CG, included higher percentages of participants with chronotropic insufficiency and abnormal 6MWD (23.08% vs. 3.57%, and 34.61% vs. 3.57%, respectively). The CHB-group was 8.1 and 14.3 times more likely to have chronotropic insufficiency and abnormal 6MWD than the CG, respectively. CHB accelerated the aging of the cardiorespiratory and muscular chain by 11 years.

Conclusion

Non-cirrhotic CHB may contribute to reduced submaximal aerobic capacity and acceleration of cardiorespiratory and muscular chain aging.

Do Child-Turcotte-Pugh and nutritional assessments predict survival in cirrhosis: A longitudinal study

BACKGROUND

Cirrhotic patients face heightened energy demands, leading to rapid glycogen depletion, protein degradation, oxidative stress, and inflammation, which drive disease progression and complications. These disruptions cause cellular damage and parenchymal changes, resulting in vascular alterations, portal hypertension, and liver dysfunction, significantly affecting patient prognosis.

AIM

To analyze the association between Child-Turcotte-Pugh (CTP) scores and different nutritional indicators with survival in a 15-year follow-up cohort.

METHODS

This was a retrospective cohort study with 129 cirrhotic patients of both sexes aged > 18 years. Diagnosis of cirrhosis was made by liver biopsy. The first year of data collection was 2007, and data regarding outcomes were collected in 2023. Data were gathered from medical records, and grouped by different methods, including CTP, handgrip strength, and triceps skinfold cutoffs. The prognostic values for mortality were assessed using Kaplan-Meier curves and multivariate binary logistic regression models.

RESULTS

The coefficient for CTP was the only statistically significant variable (Wald = 5.193, P = 0.023). This suggests that with a negative change in CTP classification score, the odds of survival decrease 52.6%. The other evaluated variables did not significantly predict survival outcomes in the model. Kaplan-Meier survival curves also indicated that CTP classification was the only significant predictor.

CONCLUSION

Although different classifications showed specific differences in stratification, only CTP showed significant predictive potential. CTP score remains a simple and effective predictive tool for cirrhotic patients even after longer follow-up.

Prevalence of under-nutrition and associated factors among patients with liver cirrhosis at a tertiary hospital in Ethiopia

Liver cirrhosis is a major health burden, resulting in over 1 million deaths per year worldwide. Nutritional imbalance often complicates the course of liver diseases, particularly of cirrhosis and has been linked to increased mortality. Despite the high disease burden, there is paucity of literature regarding the magnitude of under-nutrition in patients with cirrhosis and its associated factors in Ethiopia and sub-Saharan Africa. The study aimed to assess the prevalence of under-nutrition and its associated factors among adult out-patients with liver cirrhosis. A hospital-based cross-sectional study was conducted among 136 adult out-patients with cirrhosis who visited the hepatology clinic of St. Paul's Hospital Millennium Medical College. Data were obtained through patient interviews, medical record reviews, anthropometric and handgrip strength measurements and collected using a structured checklist and analyzed using Statistical Package for the Social Sciences (SPSS) version 26.0. Body mass index with cutoff points adjusted for the degree of ascites were used to diagnose under-nutrition. Descriptive statistical tools and binary and multivariable logistic regression analyses were employed, and statistical significance was set at <0.05. The mean age of study participants was 39.5 years (standard deviation: ±11.2) and 62.5% were males. Chronic hepatitis B virus infection (57.4%) was the most common cause of liver cirrhosis, followed by alcohol-associated liver cirrhosis (12.5%). The majority (70.6%) of the study participants were undernourished. The factors found to have statistically significant association with under-nutrition were, rural area of residence (adjusted odds ratios [AOR]: 5.65, 95% confidence interval [CI]: 1.98-16.1), presence of ascites (AOR: 2.43, 95% CI: 1.03-5.7) and the disease severity, as measured by the child-pugh class (AOR, 1.11; 95% CI: 0.45-2.7). Under-nutrition was found to be a common problem among out-patients with liver cirrhosis and patients from rural areas and those with advanced disease were disproportionately affected. It is imperative to implement routine nutritional screening and plan on appropriate interventions for patients with liver cirrhosis.

Frailty in children with chronic liver disease: Prevalence and impact on outcomes

OBJECTIVES

Frailty is a well-known complication of chronic liver disease and has been recognized as a poor prognostic factor in cirrhotic patients being associated with increased morbidity and mortality. There is limited available pediatric literature in this regard. The current study aimed to estimate the prevalence of frailty and analyze the predictive factors and their association with long-term outcomes in children with liver disease.

METHODS

Children (6-18 years of age) with cirrhotic liver disease (CLD) and noncirrhotic portal hypertension (NCPH) were prospectively enrolled. Frailty assessment was performed using the five classic Fried Frailty criteria. The children were followed up for 12 months to assess long-term outcomes.

RESULTS

The study included 170 children (CLD [n = 149; compensated CLD or CCLD, n = 109; decompensated CLD or DCLD, n = 40) and NCPH [n = 21]). The overall prevalence of frailty was 48% (40% in CCLD, 80% in DCLD group and 33% in NCPH group [p < 0.05]). Among the patients with CLD, 76 (51%) were identified as frail. Frail children had a significantly higher risk of decompensation and poorer hepatic synthetic functions, and their presence at baseline predicted future risk of decompensation, infectious complications, need for readmissions, and poor outcome (death) (p < 0.05).

CONCLUSION

There is a high prevalence of frailty in children with liver disease, which is associated with poorer clinical outcomes, including the risk of mortality. Thus, its presence in children with liver disease highlights the urgent unmet need for additional interventions to improve overall muscle mass and function.

Shared genetic architecture of non-viral cirrhosis with several pleiotropic traits: A nested case-control study in the UK Biobank

Background & Aims

Cirrhosis is a leading cause of liver-related mortality and a multifactorial disease. To date, the complex genetic architecture of non-viral cirrhosis has not been fully explored. Cross-trait genetic correlations can elucidate the common genetic etiology of genetically correlated phenotypes. This study aims to identify polygenic and pleiotropic traits associated with cirrhosis using the linkage disequilibrium score regression analysis.

Methods

We conducted genome-wide association analysis of 9,622,842 imputed SNPs on 3,368 non-viral cirrhosis cases and 258,258 controls, and cross-trait analysis between non-viral cirrhosis and various polygenic and pleiotropic traits using the UK Biobank cohort study. We further performed sensitivity analyses by removing genomic regions of alcohol intake, smoking behaviors, and obesity. We observed multiple traits showing robust genetic correlations (rg) with non-viral cirrhosis.

Results

We found strong genetic correlations between the genetic architectures of non-viral cirrhosis and clinical/physiologic factors, including BMI (rg=0.82), alanine aminotransferase (0.71), diabetes (0.70), number of cigarettes currently smoked daily (0.67), amount of alcohol drunk on a typical drinking day (0.60), insomnia (0.59), gout (0.57), depression (0.50), apoliprotein-A (-0.33), HDL cholesterol (-0.49). Exclusion of genomic regions associated with alcohol intake, smoking behaviors, and obesity demonstrated consistent directions and persistent associations in genetic patterns. The inheritability of cirrhosis on the observed scale showed 0.56%.

Conclusions

This study provides a comprehensive assessment of the shared genetic architecture of non-viral cirrhosis predisposition and numerous polygenic and pleiotropic traits, most notably BMI, alanine aminotransferase, and diabetes. These findings provide new information on underlying comorbid conditions that can increase the non-viral cirrhosis risk.

Effectiveness of different tools for malnutrition in the assessment of patients with cirrhosis

BACKGROUND

We aimed to evaluate the prevalence of malnutrition using traditional measures of nutritional assessments like body mass index (BMI), mid-arm circumference (MAC), triceps skin fold thickness (TSF), mid-arm muscle circumference (MAMC), hand grip strength (HGS) and subjective global assessments (SGA) among cirrhotic patients referred for liver transplantation (LT).

METHODS

The study was conducted among 215 cirrhotic patients referred for LT at a tertiary care hospital. Patients were enrolled between July 2021 and October 2022 to assess the prevalence of malnutrition. Patient's demographic details, clinical history, BMI using dry weight, MAMC, HGS, SGA score and disease severity were assessed.

RESULTS

Chronic alcoholism was the main causative factor for cirrhosis, followed by viral infection. 58% of cirrhotic patients were moderately to severely malnourished based on SGA, 12% were undernourished based on BMI, 91% had low MAC, and 94% had low HGS/muscle strength indicating malnutrition. Low MAC (p = 0.048) and SGA (p = 0.000) were associated with CTP - B and C class, and low MAC (p = 0.046), low TSF (p = 0.005), and SGA (p = 0.000), were associated with MELD Na score >15. Low MAC (p = 0.011) and SGA (P = 0.000) were associated with mortality, although 78% of patients had MAC within the normal range. A strong association exists between malnutrition and complications, liver disease severity, and death.

CONCLUSION

In patients with chronic liver diseases, SGA performed well as a good predictor of malnutrition, this might be because SGA analyzes various domains which can be affected in chronic liver disease. Assessing malnutrition early may help in initiating appropriate medical nutritional therapy.

Are sarcopenia, frailty and malnutrition prognostic markers of liver disease decompensation in the ambulatory setting? - A prospective cohort study

BACKGROUND

sarcopenia, frailty and malnutrition are associated with adverse outcomes in liver cirrhosis. Studies assessing the prognostic value of these conditions in ambulatory patients with cirrhosis are scarce.

METHODS

a prospective cohort study was performed, with consecutive inclusion of all patients with cirrhosis observed in the Hepatology outpatient clinic of a Portuguese tertiary center. At study enrolment, evaluation of muscle mass (ultrasound quadriceps femoris thickness), muscle strength (handgrip dynamometry) and nutritional status (Patient-Generated Subjective Global Assessment Short Form) were performed. Follow-up ended upon the occurrence of a composite endpoint, comprising of liver decompensation events and liver-related death, or last medical appointment/non-liver related death before the end of the study. The prognostic value of anthropometrical parameters and nutritional status in the composite endpoint was assessed using a multivariate Cox regression analysis, adjusted for several confounders.

RESULTS

ninety patients were enrolled (80 % male), with a mean age of 63.5 ± 10.5 years. The median follow-up was 30 (interquartile range 38) weeks, during which, 12 patients reached the composite endpoint. These patients presented a lower mean handgrip strength (23.1 ± 6.41 vs 30.3 ± 10.4 kg, p = 0.04) compared to patients who did not reach the composite endpoint. However, Cox regression multivariate analysis did not find any independent predictors of the composite endpoint, apart from previous decompensation episodes.

CONCLUSION

in this study, muscle strength was lower in the group of patients with cirrhosis who presented a liver-related event. Handgrip strength might be a promising tool in the ambulatory setting to identify patients at risk of liver decompensation and liver-related death in the short term.

SARC-F Score: A Quick Bedside Tool to Screen Sarcopenia in Patients With Cirrhosis

Background

Sarcopenia is often ignored in clinical practice despite being an important prognostic marker. SARC-F is a simple bedside score to assess muscle abnormalities in cirrhosis patients. However, there is limited Indian data on the validity of this score. Hence, we aimed to assess the validity of SARC-F score in a tertiary care center.

Methods

A prospective observational study including consecutive 100 cirrhosis patients attending the gastroenterology outpatient department in Osmania Medical College and Hospital, Hyderabad, India, was conducted from Jan 2018 to Dec 2019. The primary aim was to assess the mean muscle volume loss (MVL) by computed tomography and handgrip (HG) strength for muscle strength decline (MSD) and compare the SARC-F score with standard cut-off values.

Results

We included 100 cirrhosis patients (mean age: 45 years; males: 86%; child-pugh class B/C: 42/58). Sixty-nine percent of the patients had a SARC-F score of ≥4, whereas MVL and MSD were noted in 62% and 86% patients, respectively. Mid-arm circumference, skin-fold thickness, mid-arm muscle circumference (MAMC), and HG strength were significantly lower in patients with SARC-F score ≥4 than in those with SARC-F score <4 (P < 0.05). The Pearson correlation plot suggested a significant inverse correlation between the SARC-F score and MSD and SARC-F score and MVL. A SARC-F score of ≥4 had a sensitivity and specificity of 80.7% and 50% for MVL and 75.6% and 71.4% for MSD, respectively, whereas it was 83.3% and 52.5% for MSD and MVL combined, respectively. Area under the receiver operating characteristic curve for SARC-F as a predictor of MVL was 0.75 (95% confidence interval: 0.64-0.82; P=<0.001). On multivariate analysis, a high SARC-F score and low MAMC were predictive of MVL in cirrhosis patients.

Conclusion

SARC-F score has good sensitivity as a bedside screening tool for sarcopenia in patients with cirrhosis. A high SARC-F score and low MAMC indicates the presence of MVL and warrants further evaluation for sarcopenia.

Handgrip strength: Best practice for a rapid nutrition screening and risk stratification in male patients with alcoholic liver cirrhosis, a classification and regression tree analysis study

BACKGROUND

Rapid nutrition screening (NS) is vital for apt management in patients with alcoholic liver cirrhosis (ALC).

AIM

To identify a quick method of NS having high reliability and prognostic significance.

METHODS

NS of patients with ALC was assessed using mid-upper arm circumference (MUAC), handgrip strength (HGS), fat-free mass index (FFMI), and the Royal Free Hospital-Global Assessment (RFH-GA). Baseline clinical and biochemical information were recorded along with 90-day survival data. The classification and regression tree method was used to classify HGS, MUAC, and FFMI values as well nourished (WN), moderately malnourished (MM), and severely malnourished (SM), and their concordance with RFH-GA categories was assessed using Kendall tau-b coefficient. The prognostic proficiency of each method was tested by Cox regression analysis.

RESULTS

According to the RFH-GA, of 140 male patients with ALC, 13 of 140 (9.3%) were WN, 93 of 140 (66.4%) were MM, and 34 of 140 (26.8%) were SM. HGS has the strongest association with the RFH-GA (Kendall tau-b = 0.772; diagnostic accuracy -81.4%). HGS was found to be the independent predictor of 90-day mortality (26 of 140 [18.6%]; hazard ratio, 0.93; 95% CI, 0.88-0.98; P = 0.002) after adjusting for age, body mass index, and disease severity. The hazard of mortality was 8.5-times higher in patients with ALC with HGS < 22 kg as compared with those with HGS > 29.

CONCLUSION

HGS is a reliable tool for rapid NS. HGS < 22 kg suggests a high risk for severe malnutrition and is strongly associated with short-term mortality in male patients with ALC.

Nutrition in Pediatric Liver Disease

In liver disease, there is derangement of appetite, digestion, absorption, assimilation, storage and metabolism of both macro and micronutrients. These derangements have an impact on mortality and morbidity associated with liver diseases. In infants, breast feeds should not be stopped unless there are compelling reasons such as underlying metabolic problem. Parenteral nutrition should be considered only if, oral or nasogastric feeding is not possible. The effect of malnutrition on liver disease and impact of liver failure on nutrition is vicious and nutritional intervention has to be done at the earliest to break that vicious cycle. This chapter gives an overview of nutritional management in acute and chronic liver diseases in children and also its impact on specific clinical scenarios including liver transplantation.

Etiological Spectrum of Cirrhosis in India: A Systematic Review and Meta-analysis

BACKGROUND

Cirrhosis is a significant cause of morbidity and mortality globally and in India. This systematic review and meta-analysis aimed to ascertain the etiological spectrum and changing trends of cirrhosis in India.

METHODS

We searched electronic databases, including Pubmed/Medline, Scopus, and Embase. We included original studies that reported the etiology of cirrhosis in the Indian population.

RESULTS

We included 158 studies (adults: 147, children: 11). The overall pooled estimate of alcohol as a cause of cirrhosis in adults was 43.2% (95% confidence interval (CI) 39.8-46.6%; I2 = 97.8%), followed by nonalcoholic fatty liver disease (NAFLD)/cryptogenic in 14.4%, 95% CI (11.7-17.3%; I2 = 98.4%), hepatitis B virus (HBV) in 11.5%, 95% CI (9.8-13.3%; I2 = 96.6%), and hepatitis C virus (HCV) in 6.2%, 95% CI (4.8-7.8%; I2 = 97.2%) of the included patients. The most common cause of cirrhosis in all zones was alcohol-related. Comparison of etiologies over time revealed a reduction in the viral hepatitis-related and an increase in the proportion of alcohol-related and NAFLD/cryptogenic-related cirrhosis. The overall pooled estimates of various etiologies in children were: HBV in 10.7%, 95% CI (4.6-18.7%; I2 = 91.0%), NAFLD/Cryptogenic in 22.3%, 95% CI (9.0-39.2%; I2 = 96.7%), and HCV in 2.0%, 95% CI (0.0-8.5%; I2 = 94.6%).

CONCLUSIONS

Alcohol is the most common etiology of cirrhosis in adults in India. The proportions of alcohol and NAFLD-related cirrhosis are increasing, and those of viral hepatitis-related cirrhosis are reducing. The results of our meta-analysis will help formulate health policies and the allocation of resources.

Evaluation of muscle strength and quality in North African patients with chronic hepatitis B: A pilot case control study

Early detection of alteration of muscle strength, quantity, and quality, and sarcopenia is useful in non-cirrhotic chronic hepatitis B (NC-CHB) patients. Studies, which explored the handgrip strength (HGS) are scarce with questionable results, and no previous case-control study explored the presence of sarcopenia.The aim of this study was to assess the muscle strength [i.e.; HGS absolute (HGS_A), HGS_A/body mass index (BMI)], muscle quantity [i.e.; appendicular skeletal muscle (ASM), ASM/height², ASM/total body weight (TBW), ASM/BMI], and muscle quality [i.e.; HGS_A/total muscle mass (TMM), HGS_A/ASM] of NC-CHB patients.This was a case-control study. Cases (n = 26) were untreated NC-CHB patients, and controls (n = 28) were 'apparently' healthy participants. Muscle mass was estimated via the TMM (kg) and ASM (kg). Muscle strength was evaluated via the HGS data [i.e.; HGS_A (kg), HGS_A/BMI (m²)]. Six variants of HGS_A were determined: highest values for the dominant and non-dominant hands, highest value between the two hands, averages of the three measurements for the two hands, and the average of the highest values of the two hands. Muscle quantity was expressed in three relative variants (ASM/height², ASM/TBW, and ASM/BMI). Muscle quality was evaluated via relative HGS data adjusted by muscle mass (i.e.; HGS_A/TMM, HGS_A/ASM). Probable and confirmed sarcopenia were retained in front of low muscle strength, and low muscle strength and muscle quantity or quality, respectively.There were no significant differences between controls and NC-CHB patients in values of muscle i) Strength whatever the HGS' mode of expression (e.g.; HGS_A/BMI: 1.59 ± 0.54 vs. 1.53 ± 0.54 m², p = 0.622, respectively), ii) Quantity (e.g.; ASM/BMI: 0.79 ± 0.24 vs. 0.77 ± 0.23 m², p = 0.883), and iii) Quality (e.g.; HGS_A/ASM: 2.00 ± 0.25 vs. 2.01 ± 0.41, p = 0.952, respectively). One NC-CHB participant had a confirmed sarcopenia.To conclude, both controls and NC-CHB patients had similar HGS values. Only one NC-CHB patient had a confirmed sarcopenia.

Nutrition in Liver Disease - A Review

PURPOSE OF REVIEW : Nutrition is commonly overlooked in chronic liver disease. Both obesity and malnutrition are independent risk factors of poor prognosis in cirrhosis. This review aims to summarize the current literature regarding how nutrition contributes to liver disease, how to screen patients, and what nutritional and activity recommendations can help prevent adverse outcomes. RECENT FINDINGS: Screening for malnutrition, obesity, and sarcopenia through ambulatory bedside methods is recommended every 8-12 weeks in high risk patients. A Mediterranean diet with emphasis on high protein intake of 1.2-1.5 g/kg/day, and increasing physical activity can help to improve nutritional status. It remains critical to screen and identify patients with liver disease for malnutrition, obesity, and sarcopenia. Identifying an individualized action plan through a multidisciplinary approach can be helpful. Dietary recommendations to improve outcomes should be based on well-studied approaches. These can include the use of the Mediterranean diet in those with metabolic dysfunction-associated steatotic liver disease (MASLD) and a high protein diet in those with cirrhosis and sarcopenia. Routine assessment of improvement or decline should continue throughout a patient's clinical course.

Risk of malnutrition assessment in hospitalised adults: A scoping review of existing instruments

AIMS AND OBJECTIVES

The aim of this study was to find tools for screening the risk of malnutrition in adult hospitalised patients, evaluate their key characteristics including selected psychometric properties and propose the most appropriate tools for nursing practice.

BACKGROUND

A large number of existing tools for nutritional screening make it difficult to be aware of all the possibilities and especially to select the optimal tool.

DESIGN

The research methodology was designed as secondary research using a scoping review search to map and compare existing tools for assessing the risk of malnutrition in hospitalised adults.

METHODS

The analysis focused on the selected psychometric properties of the instruments (sensitivity, specificity, positive and negative predictive value) and key characteristics relevant to the selection of an appropriate instrument. This study follows the PRISMA-ScR Checklist.

RESULTS

The review included 27 publications containing 17 tools. The best sensitivity (57%-100%) and specificity (76%-96%) were achieved by the Malnutrition Universal Screening Tool (MUST) and the Nutritional Risk Screening 2002 (NRS 2002). Minimal Eating Observation and Nutrition Form-Version II (MEONF-II) has solid sensitivity (up to 73%), specificity (88%) and high positive predictive values (81%-82%).

CONCLUSIONS

The MUST, NRS 2002 and MEONF-II showed satisfactory psychometric properties. MEONF-II and MUST are able to assess risk without weighing the patient. The Hand Grip Strength (HGS) assessment can be recommended to detect reductions in muscle strength.

RELEVANCE TO CLINICAL PRACTICE

We recommend the MUST, NRS 2002 and MEONF-II tools for use in clinical practice, as they have the best psychometric properties and are user-friendly. The HGS, which proved to be related to the length of hospital stay (LOS) and used as an indicator of protein-energy malnutrition in obese patients, may be a useful complementary tool. For nursing practice, we recommend selecting a tool with respect to the specifics of a particular workplace.

Protein Catabolism and the Dysregulation of Energy Intake-Related Hormones May Play a Major Role in the Worsening of Malnutrition in Hospitalized Cirrhotic Patients

Malnutrition in cirrhotic patients is extremely common and has a multifactorial aetiology, whose constitutive elements have not been completely elucidated yet. Protein depletion is particularly important and an imbalance of hormones regulating hunger and satiety may be an important additive factor. The diagnosis and treatment of malnutrition are extremely important since malnutrition is associated with higher complication rates and mortality. Our observational study aimed to study protein status and energy intake-related hormone levels in a cohort of hospitalized cirrhotic patients. We enrolled 50 hospitalized and clinically stable cirrhotic patients and assessed their nutritional status with anthropometric measurements and nitrogen balance. In a subgroup of 16 patients and 10 healthy controls, circulating ghrelin and leptin levels were studied. We observed that 60% of our patients were malnourished on the basis of the mid-arm muscle circumference values; the recorded daily protein intake was tendentially insufficient (mean protein intake of 0.7 ± 0.5 g protein/kg vs. recommended intake of 1.2–1.5 g of protein/kg/die). Cirrhotic patients had lower circulating levels of both ghrelin and leptin compared to healthy controls. In conclusion, hospitalized cirrhotic patients face a catabolic state and an imbalance in hormones regulating food intake and satiety, and these elements may play a major role in the genesis and/or the worsening of malnutrition.

Implementation of Hospital-to-Home Model for Nutritional Nursing Management of Patients with Chronic Kidney Disease Using Artificial Intelligence Algorithm Combined with CT Internet

The objective of this study was to evaluate the application value of “Internet + hospital-to-home (H2H)” nutritional care model using the improved wavelet transform algorithm based on computed tomography (CT) images in the nutritional care management of chronic kidney disease (CKD) stages 3-5. A total of 120 patients with CKD were the research objects and they were randomly divided into two groups. The normal nutritional nursing model was used for nursing of patients in the control group, and the “Internet + H2H″ model was used for the observation group (H2H group), with 60 cases in each group. The nursing effect was evaluated using 320-slice volume CT low-dose perfusion imaging images, anthropometry, laboratory biochemical tests, and other survey scores. The results showed that compared with the mean filter denoising (MFD) algorithm and the orthogonal wavelet denoising (OWD) algorithm, the mean square error (MSE) and signal noise ratio (SNR) values of the IWT algorithm were better (40.0781 vs 45.2891, 59.2123)/(20.0122 vs 18.2311, 15.7812) (P < 0.05). The arm muscle circumference (MAC) (239.77 ± 18.24 vs 243.94 ± 18.72 mm) and triceps skindold (TSF) value (8.87 ± 2.74 vs 10.04 ± 2.90 mm) of the patients in the H2H group were greatly improved after the nursing (P < 0.05). For biochemical indicators, serum albumin (ALB) (35.22 ± 4.98 vs 45.32 ± 4.21) g/L, prealbumin (PAB) (289.94 ± 72.99 vs 341.79 ± 74.45) mg/L, hemoglobin (Hb) (97.62 ± 24.87 vs 110.65 ± 28.83) g/L, and blood urea nitrogen (BUN) (15.74 ± 9.87 vs 11.06 ± 5.69) mmol/L of patients in H2H group were improved (P < 0.05). After nursing, the nutritional screening score of the H2H group was obviously improved (83.33% (before) vs 50% (after)), the total score of health quality assessment (114.89 ± 5.23) in the H2H group was much higher than that of the control group (87.22 ± 14.89), and the satisfaction on the nursing model was higher in the H2H group (100% vs 71.67%) (P < 0.05). The renal cortex BF before and after nursing was significantly different between the two groups of patients (P < 0.05), and the BE of the H2H group was significantly higher than that of the control group after treatment ((335.12 ± 52.74) mL·100 g⁻¹·min⁻¹ vs (289.90 ± 53.91) mL·100 g⁻¹·min⁻¹) (P < 0.05). In summary, the “Internet + H2H″ nutritional nursing model was more individualized, which can better improve the physical quality of patients with stages 3-5 of CKD, improve the psychological state of patients, and further enhance the prognosis of the disease. In addition, the IWT algorithm showed better effects in the processing of the image of 320-slice volume CT low-dose perfusion imaging, and it was worthy of clinical application.

Deficiency, incapacity and social disadvantage of patients with chronic hepatitis B: a case-control study

INTRODUCTION

Studies examining impairment, disability and social disadvantage of patients with chronic viral hepatitis B (CHB) are scarce and present conflicting conclusions.

AIM

To assess the deficiency, incapacity, and social disadvantage of patients with CHB.

METHODS

This is a project of a case-control study with two age-matched groups. Cases (n=27) will be untreated patients with a CHB. Controls (n=27) will be healthy participants. The following data will be collected: deficiency [anthropometric, biochemical (renal and hepatic functions, lipid balance, and inflammatory markers), haematological, virological, handgrip-strength, and spirometric data], incapacity [6-min walk distance, number of stops, oxy-haemoglobin saturation, dyspnoea (visual analogue scale), heart-rate, and blood-pressure] and social disadvantage ["chronic liver disease" and physical-activity questionnaires]. Each spirometric data < lower-limit-of-normal will be considered abnormal. A handgrip-strength <26 kg (male) or <16 kg (female) will be considered low. The signs of walking intolerance will be: stop during the walk, 6-min walk distance ≤ lower-limit-of-normal, dyspnoea at the end of the walk> 5/10, drop in oxy-haemoglobin saturation >5 points, heart-rate at the end of the walk ≤60%. A total physical-activity score <9.42 will classify the participant as sedentary.

EXPECTED RESULTS

Compared with controls, cases will have a marked alteration of submaximal aerobic data. These alterations will worsen quality-of-life and may be related to muscle and/or spirometric abnormalities, and supported by systemic inflammation and high viral load.

Handgrip strength as a surrogate marker of lean mass and risk of malnutrition in paediatric patients

BACKGROUND & AIMS

The use of handgrip strength (HGS) as a proxy of nutritional status in sick children has not been studied. This study created HGS centile charts in healthy children and explored the utility of HGS z-scores as markers of body composition and screening of malnutrition risk in sick children.

METHODS

Data from 535 healthy children aged 5-16 years were used for the development of HGS centiles adjusted either for age or height. In 595 sick children, relationships between HGS z-scores with body composition, malnutrition risk (Paediatric Yorkhill Malnutrition Score-PYMS), length of hospital stay (LOS) and biomarkers of disease severity were explored. The use of HGS z-score to identify sick children in need of further dietetic assessment was investigated.

RESULTS

Children scoring at high malnutrition risk with PYMS had lower HGS z-scores for age (by 0.51 SD, p < 0.001) and height (by 0.46 SD, p = 0.001) than those who scored low. A HGS z-score at cut-offs of -0.81 SD and -1.2 SD for age and height, respectively, was predictive of need for dietetic intervention in sick children with sensitivity of 79% and 70% and specificity of 56% and 69%, respectively. HGS z-scores were predictive of fat free mass (FFM) in sick and healthy (all p < 0.001) children, while fat mass was not. HGS z-scores were inversely related with plasma CRP (rho, age: -0.21; height: -0.23, both p = 0.001). HGS was not predictive of LOS.

CONCLUSION

HGS is predictive of FFM, could compliment assessment of malnutrition risk, and may help identify children for further dietetic intervention on admission to hospital.

Malnutrition and liver disease in a developing country

Malnutrition is a highly prevalent and under recognized condition in developing countries of South Asia. The presence of malnutrition causes a severe impact on patients with liver cirrhosis. The etiology of cirrhosis differs in the South Asian region compared to the West, with hepatitis B and C still being the leading causes and the prevalence of nonalcoholic fatty liver disease increasing over time. Comorbid malnutrition worsens outcomes for cirrhosis patients. Urgent attention to address malnutrition is needed to improve patient outcomes. The etiology and pathophysiology of malnutrition in liver diseases is multifactorial, as reduction in liver function affects both macronutrients and micronutrients. A need for nutritional status assessment for liver disease patients exists in all parts of the world. There are many widely studied tools in use to perform a thorough nutritional assessment, of which some tools are low cost and do not require extensive training. These tools can be studied and evaluated for use in the resource limited setting of a country like Pakistan. Treatment guidelines for proper nutrition maintenance in chronic liver disease exist for all parts of the world, but the knowledge and practice of nutritional counseling in Pakistan is poor, both amongst patients and physicians. Emphasis on assessment for nutritional status at the initial visit with recording of vital signs is needed. Simultaneously, treating physicians need to be made aware of the misconceptions surrounding nutritional restrictions in cirrhosis so that patient education is done correctly based on proper scientific evidence.

A narrative review of malnutrition in chronic liver disease

Interest in research on malnutrition is decreasing due to thoughts that the problem of malnutrition has been solved in an age of over-nourishment or obesity and defining malnutrition is not uniform. This study aimed to critically appraise the prevalence of malnutrition according to various diagnostic tools and proportion of severity used in previous studies. A literature review was performed using a total of 16 studies published between 1980 and 2020 regarding malnutrition in patients with chronic liver disease. Most of the analyzed studies were conducted before 2010, and only a few studies were conducted after 2010. Nutrition assessment tool (NAT) and nutrition screening tool (NST) to explain malnutrition were distinguished; however, there was no clear distinction between them. NST often used questionnaires while NST used various malnutrition measuring tools. Our results show that, in the age of over-nourishment, reduction in malnutrition in chronic liver disease still hasn’t been significant. Malnutrition prevalence in studies published prior to 2,000 ranged between 13.3% and 85% (mean, 37.6%), whereas that in studies published after 2,000 ranged between 13.3% and 78.5% (mean, 35.2%). Malnutrition prevalence largely depends on the diagnostic tool and proportion of disease severity in the target population. The prevalence of malnutrition in patients with chronic liver diseases varies widely. This big difference is related to various diagnostic tools, mixed etiologies, and different disease severity in different studies. The prevalence of malnutrition was 36.4% (10–80.3%) in all patients with liver disease, 39.9% (13.3–80.3%) in compensated liver disease, and 44.1% (26.7–93.6%) in decompensated cirrhosis. Malnutrition prevalence was 38.2% and 23.7% in alcoholism-related and hepatitis C virus (HCV)-related diseases, respectively. Malnutrition also largely depended on the judgement tool. Malnutrition prevalence according to the diagnostic tool was approximately 28–85% for subjective global assessment (SGA), 30.8–78.5% for anthropometric approach, and 21–80.3% for clinical judgment. It became similar over time.

Nutritional assessment and factors affecting dietary intake in patients with cirrhosis: A single-center observational study

OBJECTIVES

Malnutrition is predictor of morbidity and mortality in patients with cirrhosis. We investigated prevalence of malnutrition and factors affecting dietary intake in patients with cirrhosis.

METHODS

Single-center cross-sectional observational study. A total of 251 patients with cirrhosis underwent dietary and nutritional assessment by subjective global assessment (SGA) and anthropometric measurement (dry body mass index, midarm circumference, midarm muscle circumference, triceps skinfold thickness, handgrip strength). Dietary intake was assessed in terms of total calories and protein intake, percentage of recommended intake, and per kilogram body weight per day. Factors influencing dietary intake were also assessed.

RESULTS

Of 251 patients 199 (79%) were male and 52 (21%) were female (mean age, 51 ± 14 y, Child's A:B:C: 83:116:52). In SGA analysis 87 (35%) were well nourished (SGA-A), 106 (42%) were moderately nourished (SGA-B), and 58 (23%) were severely malnourished (SGA-C). Patients with Child's C score were severely malnourished compared with patients with Child's B and A scores. Midarm circumference, midarm muscle circumference, triceps skinfold thickness, and handgrip strength were significantly higher in SGA-A than SGA-B and SGA-C. Patients in SGA-A (1939 ± 479 kcal/d) consumed significantly higher calories than SGA-B (1494 ± 216 kcal/d) and SGA-C (1321 ± 213 kcal/d). Percentage of recommended calories intake (SGA-A [76%], SGA-B [61%], SGA-C [59%], P = 0.001) and calories/kg/d is also higher in SGA-A than SGA-B and SGA-C. The results with protein intake were similar (SGA-A [61 ± 14 gm/d], SGA-B [56 ± 7 gm/d], SGA-C [51 ± 9 gm/d], P = 0.001). Protein intake in g/kg/d is significantly lower in SGA-C (0.76 ± 0.22) than SGA-B (0.85 ± 0.2) and SGA-A (0.93 ± 0.2). A total of 61% patients were vegetarian, and 84% did not take evening snacks. Poor appetite (n = 68, 27%), early satiety (n = 75, 30%), abdominal fullness (n = 62, 25%), low-salt diet (n = 52, 21%), and social myth about diet 43(17%) were the common reasons for poor intake. Distension of abdomen, social myth about diet, and low sodium in diet were key factors affecting dietary intake in patients with cirrhosis and malnutrition.

CONCLUSIONS

Malnutrition seen in 65% of patients. Total calories and protein intake was significantly low compared with recommendation even in well-nourished patients. Distension of abdomen, social myth about diet, and low sodium in diet were key factors affecting dietary intake in patients with cirrhosis and malnutrition.

Nutritional Assessment and Malnutrition in Patients With Cirrhosis

We sought to determine the incidence and outcomes of malnutrition in patients with cirrhosis. We performed a retrospective chart review of 134 patients listed for liver transplant (LT) to assess the presence and degree of malnutrition identified by the Subjective Global Assessment score at the time of initial transplant evaluation, follow-up nutrition visits, and at the time of transplant. Number of admissions/readmissions to the hospital, reason for hospitalization(s), and length of stay were determined. Malnutrition was prevalent at initial nutrition visit (51.9%) and underdiagnosed. By the time of transplant, 61% of the patients were identified as malnourished. Most patients (52%) were awaiting LT for more than 180 days. The change in Subjective Global Assessment score after the initial nutrition assessment was statistically significant (p ≤ .007), with worsening malnutrition severity. Seventy-one patients (53%) required hospitalization while awaiting transplant, with a median hospital stay of 9 days. Nutrition expertise is required for prompt and accurate diagnosis of malnutrition in patients with cirrhosis. Nurses caring for patients with advanced liver disease are in a prime position to provide guidance to optimize patient outcomes.

Royal Free Hospital-Nutritional Prioritizing Tool improves the prediction of malnutrition risk outcomes in liver cirrhosis patients compared with Nutritional Risk Screening 2002

The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines recommend the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) to identify malnutrition risk in patients with liver disease. However, little is known about the application of the RFH-NPT to screen for the risk of malnutrition in China, where patients primarily suffer from hepatitis virus-related cirrhosis. A total of 155 cirrhosis patients without liver cancer or uncontrolled co-morbid illness were enrolled in this prospective study. We administered the Nutritional Risk Screening 2002 (NRS-2002), RFH-NPT, Malnutrition Universal Screening Tool (MUST) and Liver Disease Undernutrition Screening Tool (LDUST) to the patients within 24 h after admission and performed follow-up observations for 1·5 years. The RFH-NPT and NRS-2002 had higher sensitivities (64·8 and 52·4 %) and specificities (60 and 70 %) than the other tools with regard to screening for malnutrition risk in cirrhotic patients. The prevalence of nutritional risk was higher under the use of the RFH-NPT against the NRS-2002 (63 v. 51 %). The RFH-NPT tended more easily to detect malnutrition risk in patients with advanced Child–Pugh classes (B and C) and lower Model for End-stage Liver Disease scores (<15) compared with NRS-2002. RFH-NPT score was an independent predictive factor for mortality. Patients identified as being at high malnutrition risk with the RFH-NPT had a higher mortality rate than those at low risk; the same result was not obtained with the NRS-2002. Therefore, we suggest that using the RFH-NPT improves the ability of clinicians to predict malnutrition risk in patients with cirrhosis primarily caused by hepatitis virus infection at an earlier stage.

Reduced handgrip strength is predictive of poor survival among patients with liver cirrhosis: A sex-stratified analysis

AIM

Handgrip strength (HGS) is a marker of sarcopenia and has been used to stratify an individual's risk of death. We aimed to assess the prognostic significance of HGS in patients with liver cirrhosis.

METHODS

In this retrospective study, we collated data of 563 consecutive patients admitted to our hospital with cirrhosis (375 men). A dynamometer was used to measure HGS. Body composition (including skeletal muscle and adipose tissue volumes) was estimated using computed tomography. Predictors of mortality were identified using sex-stratified multivariate analyses.

RESULTS

After adjustments for age, cirrhosis etiology, Child-Pugh score, and other confounding variables, HGS, but not body composition, was independently associated with mortality in male patients (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.94-0.99; P < 0.01) and female patients (HR, 0.91; 95% CI, 0.84-0.99; P = 0.02). Men with low HGS (<30 kg) had a higher risk of mortality (HR, 2.09; 95% CI, 1.39-3.17; P < 0.001), as did women with low (<15 kg) HGS (HR, 2.14; 95% CI, 1.16-4.01; P = 0.02). We could stratify the sex-specific risk of mortality in cirrhotic patients using HGS, regardless of coexistent hepatocellular carcinoma and the Child-Pugh class.

CONCLUSIONS

Reduced HGS, rather than skeletal muscle and adipose tissue volumes, is associated with an increased risk of mortality in patients of both sexes with liver cirrhosis. Measurement of HGS is a simple, cost-effective, and appropriate bedside assessment for the prediction of survival in patients with cirrhosis.

Surgery in Patients with Portal Hypertension

Patients with portal hypertension will increasingly present for nontransplant surgery because of the increasing incidence of, and improving long-term survival for, chronic liver disease. Such patients have increased perioperative morbidity and mortality caused by the systemic pathophysiology of liver disease. Preoperative assessment should identify modifiable causes of liver injury and distinguish between compensated and decompensated cirrhosis. Risk stratification, which is crucial to preparing patients and their families for surgery, relies on scores such as Child-Turcotte-Pugh and Model for End-stage Liver Disease to translate disease severity into quantified outcomes predictions. Risk factors for postoperative complications should also be recognized.

Nutrition Support of Children With Chronic Liver Diseases: A Joint Position Paper of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition

Chronic liver disease places patients at increased risk of malnutrition that can be challenging to identify clinically and treat. Nutrition support is a key aspect of the management of these patients as it has an impact on their quality of life, morbidity, and mortality. There are significant gaps in the literature regarding the optimal nutrition support for patients with different types of liver diseases and the impact of these interventions on long-term outcomes. This Position Paper summarizes the available literature on the nutritional aspects of the care of patients with chronic liver diseases. Specifically, the challenges associated with the nutritional assessment of these subjects are discussed, and recently investigated approaches to determining the patients' nutritional status are reviewed. Furthermore, the pathophysiology of the malnutrition seen in the context of chronic liver disease is summarized and monitoring, as well as treatment, recommendations are provided. Lastly, suggestions for future research studies are described.

Optimizing the Nutritional Support of Adult Patients in the Setting of Cirrhosis

Aim: The aim of this work is to develop a pragmatic approach in the assessment and management strategies of patients with cirrhosis in order to optimize the outcomes in this patient population. Method: A systematic review of literature was conducted through 8 July 2017 on the PubMed Database looking for key terms, such as malnutrition, nutrition, assessment, treatment, and cirrhosis. Articles and studies looking at associations between nutrition and cirrhosis were reviewed. Results: An assessment of malnutrition should be conducted in two stages: the first, to identify patients at risk for malnutrition based on the severity of liver disease, and the second, to perform a complete multidisciplinary nutritional evaluation of these patients. Optimal management of malnutrition should focus on meeting recommended daily goals for caloric intake and inclusion of various nutrients in the diet. The nutritional goals should be pursued by encouraging and increasing oral intake or using other measures, such as oral supplementation, enteral nutrition, or parenteral nutrition. Conclusions: Although these strategies to improve nutritional support have been well established, current literature on the topic is limited in scope. Further research should be implemented to test if this enhanced approach is effective.