Effect of sarcopenia on survival in patients with cirrhosis: A meta-analysis

Effect of adipose-related parameters on mortality in patients with liver cirrhosis: a meta-analysis

BACKGROUND

Some adipose-related parameters exhibit distinct prognostic value in patients with cirrhosis. However, the magnitude and direction of the association between individual adipose parameter and mortality in patients with cirrhosis are unclear.

AIM

This study aimed to evaluate the association between individual adipose parameter and mortality in patients with cirrhosis using the meta-analysis method.

METHODS

The PubMed, Embase, Web of Science, China Biological Medicine, WanFang, and China National Knowledge Infrastructure databases were searched from inception through December 15, 2023, to identify eligible studies. The impact of each adipose parameter on mortality was assessed by the pooled unadjusted or adjusted hazard ratio (HR) with 95% confidence intervals (CIs) using the random effects model.

RESULTS

A total of 33 studies involving 9626 patients were included in our analysis, with 11 adipose parameters evaluated. The pooled prevalence of sarcopenic obesity (SO) and myosteatosis in patients with cirrhosis was 15.5% and 34.4%, respectively. In adjusted analysis, each unit increase in subcutaneous adipose tissue index (SATI) (HR: 0.99, 95% CI: 0.98-1.00) or muscle attenuation (MA) (HR: 0.94, 95% CI: 0.90-0.98) and each unit decrease in visceral-to-subcutaneous adipose tissue ratio (VSR) (HR: 1.92, 95% CI: 1.45-2.54) showed an independent association with a decreased risk of mortality. However, concurrent myosteatosis (HR: 1.88, 95% CI: 1.48-2.40) or SO (HR: 2.77, 95% CI: 1.95-3.93) significantly increased the risk of mortality in patients with cirrhosis.

CONCLUSION

Decreased SATI or MA, increased VSR, and concurrent myosteatosis or SO were independently associated with a higher risk of mortality in patients with cirrhosis.

Muscle fat content correlates with postoperative survival of viral-related cirrhosis patients after the TIPS: a retrospective study

PURPOSE

Early prediction of the prognosis of viral-related cirrhosis patients after transjugular intrahepatic portosystemic shunt (TIPS) is beneficial for clinical decision-making. The aim of this study is to explore a comprehensive prognostic assessment model for evaluating the survival outcomes of patients post-TIPS.

MATERIALS AND METHODS

A total of 155 patients treated with TIPS were included in the study. The data were collected from electronic records. The nutritional status of the patient is evaluated using imaging examinations measuring by the axial CT images from the L3 vertebral level. The primary endpoint was set as death within 1 year after TIPS. Multivariate Cox regression was performed to determine the factors associated with mortality.

RESULTS

The Cox regression analysis revealed that the lower PMFI was associated with a lower risk of all-cause mortality after TIPS (hazard ratio [HR] 1.159, 95% confidence interval [CI] 1.063-1.263, p = 0.001). Furthermore, subgroup analyses according to gender revealed the PMFI was associated with postoperative death both in male (HR 2.125, 95% CI, 1.147-3.936, p = 0.017) and female patients (HR 1.070, 95% CI, 1.001-1.144, p = 0.047). The area under the curve (AUC) for predicting death within 1 year was 0.807. The clinical impact curve analysis showed that PMFI had higher levels of risk threshold probability and a smaller gap between actual and predicted curves.

CONCLUSIONS

In viral-related cirrhosis patients with portal hypertension, increased muscle fat content might be a potential prognostic marker and associated with postoperative death after TIPS.

Multiomics Analysis and Machine Learning-based Identification of Molecular Signatures for Diagnostic Classification in Liver Disease Types Along the Microbiota-gut-liver Axis

Background

Liver disease, responsible for around two million deaths annually, remains a pressing global health challenge. Microbial interactions within the microbiota-gut-liver axis play a substantial role in the pathogenesis of various liver conditions, including early chronic liver disease (eCLD), chronic liver disease (CLD), acute liver failure (ALF), acute-on-chronic liver failure (ACLF), non-alcoholic fatty liver disease (NAFLD), steatohepatitis, and cirrhosis. This study aimed to identify key molecular signatures involved in liver disease progression by analyzing transcriptomic and gut microbiome data, and to evaluate their diagnostic utility using machine learning models.

Methods

Transcriptomic analysis identified differentially expressed genes (DEGs) that, when integrated with regulatory elements microRNAs, transcription factors, receptors, and the gut microbiome highlight disease-specific molecular interactions. To assess the diagnostic potential of these molecular signatures, a two-step analysis involving principal component analysis (PCA) and Random Forest classification was conducted, achieving accuracies of 75% for ALF and 89% for NAFLD. Additionally, machine learning algorithms, including K-neighbors, multi-layer perceptron (MLP), decision tree, Random Forest, logistic regression, gradient boosting, CatBoost, Extreme Gradient Boosting (XGB), and Light Gradient Boosting Machine (LGBM), were applied to gene expression data for ALF and NAFLD.

Results

Key genes including CLDN14, EGFR, GSK3B, MYC, and TJP2, alongside regulatory miRNAs let-7a-5p, miR-124-3p, and miR-195-5p and transcription factors NFKB1 and SP1 may be suggested as critical to liver disease progression. Additionally, gut microbiota members, Dictyostelium discoideum and Eikenella might be novel candidates associated with liver disease, highlighting the importance of the gut-liver axis. The Random Forest model reached 75% accuracy and 83% area under the curve for ALF, while NAFLD classification achieved 100% accuracy, precision, recall, and area under the curve underscoring robust diagnostic potential.

Conclusion

This study establishes a solid foundation for further research and therapeutic advancement by identifying key biomolecules and pathways critical to liver disease. Additional experimental validation is needed to confirm clinical applicability.

Nutritional and Psychological Support as a Multidisciplinary Coordinated Approach in the Management of Chronic Liver Disease: A Scoping Review

OBJECTIVES

This review emphasizes a novel, multidisciplinary, coordinated approach in the management of chronic liver diseases (CLDs).

BACKGROUND

Chronic liver diseases represent a significant global health burden, marked by a notable shift in the prevalence patterns from virus-related to metabolic and alcohol-related entities. Malnutrition, frailty, and sarcopenia exert a substantial impact on patients with cirrhosis, affecting 75%-90% of cases and escalating as the disease progresses. The European Association for the Study of the Liver recommends a comprehensive approach to nutritional care, emphasizing the need for detailed assessments in patients with cirrhosis, using diverse tools such as computed tomography scans, bioelectrical impedance analysis, and evaluations of muscle function. Considering the prevalence of nutritional and psychological disorders in the CLD population, the treatment of these patients should be founded indispensably on a multidisciplinary approach.

METHODS

A systematic search was conducted of the PubMed, MEDLINE, and SCOPUS databases to identify trials investigating the health effects of nutritional and psychological assessments in patients with CLD.

RESULTS

In dealing with the treatment of patients with CLD, an exploration of the psychological domain emerges as crucial, because psychological distress, especially depression, exerts a tangible influence on patient outcomes. Thus, the engagement of psychologists and/or psychotherapists, who might use techniques such as cognitive behavioral therapy, could enhance patients' comprehension of nutritional implications in their treatment and make them more aware of their illness.

CONCLUSION

The review emphasizes the relevance of both nutritional and psychological assessments in patients with CLD that could improve patient education on the pivotal role of nutrition in disease management. Randomized controlled trials evaluating the combined impact of nutritional and psychological support are recommended to further investigate this complex clinical landscape.

Effect of sarcopenia on the survival of patients undergoing liver transplantation: a meta-analysis

PURPOSE

The relationship between sarcopenia and post-liver transplant (LT) mortality is still not well understood. This study aims to provide an updated and comprehensive meta-analysis evaluating the impact of sarcopenia on the survival of LT patients.

METHODS

We conducted searches in PubMed, Web of Science, and EMBASE up until May 2, 2024, without language restrictions. The primary outcome measured was the overall post-LT mortality risk associated with sarcopenia. The DerSimonian-Laird random effects model was used to calculate pooled adjusted hazard ratios (HRs).

RESULTS

Eighteen cohort studies comprising a total 6297 LT patients were included. The overall prevalence of sarcopenia was 27% (95% CI: 26%-28%), and this rate was lower when sarcopenia was defined using the third lumbar-skeletal muscle index in men, and among patients with lower Child-Pugh class. Sarcopenia remained significantly associated with higher mortality, with a pooled adjusted HR of 1.55 (95% CI 1.28-1.89). This association held across subgroups based on sex, study location, sarcopenia definition, study quality, and living donor LT recipients. A sensitivity analysis excluding groups with a high proportion of hepatocellular carcinoma patients showed similar findings (HR 1.63, 95% CI 1.13-2.35). No significant heterogeneity was identified in any of the analyses.

CONCLUSIONS

This meta-analysis shows that sarcopenia is significantly associated with increased mortality after LT. Thus, the risk of sarcopenia should be factored into the initial evaluation of LT candidates.

Global prevalence, metabolic characteristics, and outcomes of lean-MAFLD: a systematic review and meta-analysis

BACKGROUND

Metabolic Dysfunction-Associated Fatty Liver disease (MAFLD) among lean individuals is increasingly recognized. We aimed to compare the prevalence, metabolic characteristics, and outcomes of lean vs overweight/obese-MAFLD patients.

METHODS

Databases of Embase, Medline, and Web of Science were searched from inception till October 2023. Only cohorts adhering to the lean-MAFLD criteria as defined by the international consensus statement were included.

RESULTS

In the pooled analysis of 10,013,382 individuals, the prevalence of lean-MAFLD in the general population was 1.94% (95% CI 1.10-3.39%, I2 = 98.7%). Lean and overweight/obese-MAFLD patients had similar metabolic characteristics for blood pressure, LDL, TG, blood glucose, and HbA1c. There was an increased incidence rate and likelihood for liver-related mortality for lean-MAFLD vs overweight/obese-MAFLD [1.33 per 1000 patient-years (95% CI 1.28-1.39) vs 0.76 (95% CI 0.25-2.28), (OR 3.56 (95% CI 3.45-3.67), p < 0.01). There were similar incidence rates and odds ratios between lean vs overweight/obese-MAFLD for: (1) all-cause mortality [10.08 per 1000 patient-years (95% CI 9.93-10.23) vs 8.94 per 1000 patient-years (95% CI 4.08-19.57), (OR 1.92 (95% CI 0.01-220.57), p = 0.33)]; (2) cardiovascular-related mortality [2.53 per 1000 patient-years (95% CI 0.65-9.96) vs 2.07 per 1000 patient-years (95% CI 0.80-5.39), (OR 1.91 (95% CI 0.02-142.76), p = 0.58)]; and (3) cancer-related mortality [3.42 per 1000 patient-years (95% CI 3.33-3.51) vs 3.15 per 1000 patient-years (95% CI 1.21-8.19), (OR 1.99 (95% CI 0.29-13.52), p = 0.13).

CONCLUSION

Lean-MAFLD patients have an equivalent metabolic burden compared to overweight/obese-MAFLD patients and thus a similar incidence rate of major extrahepatic complications. However, they have an increased risk of liver-related mortality.

Association of sarcopenia assessed by CT/MRI with treatment response and clinical outcomes in noncirrhotic primary biliary cholangitis patients

BACKGROUND AND OBJECTIVE

Sarcopenia is a common complication in patients with cirrhosis. However, research on sarcopenia in patients with noncirrhotic primary biliary cholangitis (PBC) is limited. This study aimed to investigate the prevalence of sarcopenia and the associations between concomitant sarcopenia and the biochemical response to ursodeoxycholic acid (UDCA) treatment and clinical outcomes in patients with noncirrhotic PBC.

METHODS

This retrospective study enrolled consecutive patients whose baseline visits occurred between January 2009 and December 2023. Sarcopenia was assessed via pretreatment CT or MRI at the mid-L3 level through the skeletal muscle index (SMI). Baseline characteristics, response rate after UDCA administration, liver-related events were compared. And baseline liver and plasma C-reactive protein (CRP) and IL-6 levels in a subset of patients were also evaluated.

RESULTS

A total of 164 patients were included and sarcopenia was identified in 66 (40.2 %) patients. The median duration of follow-up was 4.75 (1.71, 6.40) years. The PBC patients with sarcopenia had a lower biochemical response rate (45.9 % vs. 65.9 %; P = 0.014) after 12 months of UDCA treatment and a higher incidence of liver-related events (24.2 % vs. 11.2 %, P = 0.027) during follow-up. Furthermore, higher levels of baseline CRP and IL-6 in the plasma and liver were also observed(P < 0.05).

CONCLUSIONS

Sarcopenia was highly prevalent in patients with noncirrhotic PBC. Concomitant sarcopenia may adversely affect the biochemical response to UDCA treatment and the occurrence of liver-related adverse events in PBC patients without cirrhosis.

Diet-induced inflammation and its association with sarcopenia in an Iranian population: a case-control study

BACKGROUND

Dietary intake, as one of the critical lifestyle risk factors, plays a crucial role in the risk of sarcopenia, potentially due to its anti-inflammatory properties. The objective of this study was to evaluate the association between the Dietary Inflammatory Index (DII) and the Dietary Inflammatory Score (DIS) with sarcopenia in an Iranian population.

METHODS

In the present study, 80 participants with sarcopenia were included in the case group, and 80 non-sarcopenia participants were included in the control group, matched by gender. Sarcopenia was diagnosed according to the Asian Working Group on Sarcopenia (AWGS) guidelines. Additionally, dietary data obtained from a food frequency questionnaire were used to calculate participants' DIS and DII scores. The association between the DII and DIS and the odds ratio of sarcopenia was assessed by logistic regression in both crude and adjusted models.

RESULTS

In the crude model, the odds of sarcopenia were significantly higher for each unit increase in DIS and DII scores (DIS: odds ratio (OR) = 1.221, 95% confidence interval (CI): 1.128-1.322; DII: OR = 1.271, 95% CI: 1.041-1.553). After adjusting for age, energy, and protein intake, higher odds of sarcopenia were observed for each unit increase in DIS score (OR = 1.129, 95% CI: 1.004-1.268). Similarly, higher odds of sarcopenia were seen for each unit increase in DII score after adjusting for potential confounders (OR = 1.269, 95% CI: 1.032-1.561).

CONCLUSIONS

In conclusion, this study found that greater adherence to the DII and DIS was associated with higher odds of sarcopenia in older adults.

CLINICAL TRIAL NUMBER

Not applicable.

Phase angle as a reproducible bedside tool to assess reduced muscle mass in patients with decompensated cirrhosis and ascites: An observational cross-sectional study

BACKGROUND

Reduced muscle mass in patients with cirrhosis is linked to poor clinical outcomes. Bioimpedance analysis estimates fat mass (FM), fat-free mass (FFM), and phase angle (PhA), a marker of cell membrane integrity correlating with computed tomography-based muscle mass assessments. We hypothesized that PhA would remain stable after paracentesis.

METHODS

Bioelectrical impedance was measured in patients with cirrhosis immediately before and after paracentesis using a 256-frequency bioimpedance spectroscopy device. We assessed median paired differences (with 95% confidence intervals) for FM, FFM, and PhA. Reduced muscle mass was diagnosed using PhA thresholds of 5.4 for women and 5.6 for men, based on previous cross-sectional validation against skeletal muscle index.

RESULTS

The study included 32 participants with median age of 60 (IQR: 55-67), 60% male, median model for end stage liver disease Na (MELD-Na) score of 18 (IQR: 14-21), and median paracentesis volume of 6 liters (loss of 5.7 kg). At baseline, 97% had reduced muscle mass based on PhA thresholds. Significant differences were observed between pre-paracentesis and post-paracentesis measurements for FM and FFM (P < 0.05). PhA remained stable (P = 0.208), with a slight nonsignificant increase of 0.1° from pre-paracentesis to post-paracentesis. Sensitivity analysis showed change in reduced muscle mass diagnosis for only one participant.

CONCLUSIONS

FM and FFM levels before and after paracentesis were significantly different, suggesting that these tests would not be accurate in patients with large fluid shifts. PhA measurements were not significantly affected by ascitic fluid shifts after paracentesis, suggesting that PhA may reliably monitor muscle mass in patients, regardless of ascites.

Serum interferon-gamma-induced protein 10 levels can help predict sarcopenia development in patients with primary hepatocellular carcinoma: A retrospective cohort study

BACKGROUND

Sarcopenia is a prognostic factor in patients with hepatocellular carcinoma (HCC). However, the mechanism underlying sarcopenia development in these patients remains unclear. The chemokine interferon-gamma-induced protein 10/C-X-C motif chemokine ligand 10 (IP-10) has been found to be associated with muscle regeneration or destruction. Thus, we aimed to clarify the role of serum IP-10 levels in predicting sarcopenia development in patients with HCC.

METHODS

This retrospective study enrolled 120 patients with primary HCC whose serum IP-10 levels were measured both at baseline and 1 year after the confirmed diagnosis of HCC. Patients who had sarcopenia at baseline computed tomography imaging were assigned to the Sarco-base group, whereas those in whom sarcopenia was found for the first time after 3 years were assigned to the Sarco-develop group. Those who never met the criteria during the follow-up period were assigned to the Non-Sarco group.

RESULTS

The baseline IP-10 levels were significantly lower in the Sarco-base group compared to the rest (p = 0.016). Conversely baseline IP-10 levels and IP-10 ratio at 1 year were higher in the Sarco-develop group than in the Non-Sarco group (p = 0.0017, p = 0.025). High IP-10 levels at baseline, and high IP-10 ratios at 1 year were independently related factors for sarcopenia development.

CONCLUSIONS

Patients with sarcopenia at baseline more frequently presented with low IP-10 levels than those without. Contrarily, the group without sarcopenia at baseline and with high baseline IP-10 levels and high IP-10 ratios at 1 year were more likely to develop sarcopenia after 3 years. Monitoring of IP-10 levels may enable the identification of groups prone to develop sarcopenia in patients with HCC.

Italian inter-societal manifesto for the prevention and therapy of sarcopenia: A way to raise awareness among institutions, the healthcare world and the population by: Ministry of Health, ADI (Italian Association of Dietetics and Clinical Nutrition), SIGG (Italian Society of Geriatrics and Gerontology), SIMFER (Italian Society of Physical and Rehabilitation Medicine), SINPE (Italian Society of Artificial Nutrition and Metabolism), SINU (Italian Society of Human Nutrition), SINuc (Italian Society of Clinical Nutrition and Metabolism), SIO (Italian Society of Obesity), SISA (Italian Society of Food Science), SISDCA (Italian Society for the study of Eating Disorders)

Sarcopenia, a pathology that concerns the gradual reduction of muscle mass and strength, which entered the international classification of pathologies in 2016, is one of the most critical effects of aging (primary sarcopenia) and of some pathologies, such as oncological pathologies, lung diseases, malnutrition, and obesity (secondary sarcopenia). Going to evaluate the prevalence of the pathology, the scientific literature reports that are sarcopenic: 12-13 % of elderly living at home under 70 years of age, 24 % between 70 and 80, and up to 30-50 % of over 80; 35 % of elderly who access geriatric facilities, 15 % of subjects develop sarcopenia during hospitalization; 87 % of institutionalized elderly; 18 % of diabetic people; 20-70 % of cancer patients; 12-39 % of patients with chronic obstructive pulmonary disease; 84 % of women and 100 % of men with grade II and III obesity. Given this background, Ministry of Health and the main Italian scientific societies of clinical nutrition, geriatrics and physiatry are signatories of the opinion paper entitled "Inter-society Italian Manifesto for the prevention and therapy of sarcopenia", which is presented in this paper. The manifesto's goal is to raise awareness on sarcopenia among the population, institutions and healthcare workers through various actions, in the form of a message, awareness poster and the establishment of the "National Sarcopenia Day" by the Ministry of Health. In this day, centers where sarcopenia is diagnosed and treated, such as geriatrics, rehabilitation, and clinical nutrition facilities, carry out free screening on the target population. As regards actions for healthcare workers, it is necessary to promote and support the training of general practitioners (GPs) and of staff working in healthcare and social healthcare facilities (such as nurses, physiotherapists, speech therapists, and motor science operators so that they can recognize and adequately treat sarcopenia.

Reduced Mastication Is Associated With Dynapenia Markers in Patients With Cirrhosis: A Cross-Sectional Study

Background and Aim: Dental diseases are common in patients with cirrhosis. In these patients, reduced mastication might interfere with protein intake and contribute to malnutrition. We addressed the relationship between reduced mastication and dynapenia in patients with cirrhosis. Methods: This cross-sectional study involved patients with cirrhosis treated in a Brazilian center. Trained dentists performed oral examinations and tested the patients for nutritional parameters such as handgrip strength (HGS) and gait speed test (GST). Reduced mastication was presumed when a patient had molar edentulism (≥ 3 teeth), bad dental occlusion, or ill-fitting denture. Associations between mastication status and malnutrition were evaluated using multivariate linear regression analysis for continuous measures and adjusted prevalence ratio (PR (95% confidence interval)) for binary measures. Results: We included 149 patients with cirrhosis (60 ± 13 years old, 76% men, 64% Child A, 60% due to alcoholism only). Reduced mastication affected 107 patients (72%), low muscle strength (decreased HGS) occurred in 45 (30%), and decreased GST was observed in 58 (41%, among 143 patients able to walk). Thirty-one out of 143 (22%) presented decreased HGS and GST, characterizing dynapenia. Reduced mastication was associated either with decreased HGS [PR = 2.28 (1.08-4.81), p = 0.030; reduced mastication decreases the HGS mean by 12.5 kg for men (p < 0.001) and 8.1 kg for women (p = 0.065)] or with decreased GST [PR 1.97 (1.09-3.55), p = 0.024; reduced mastication increased the time of GST by 1.1 s on average (p = 0.005)], adjusting for age, alcoholic etiology, and Child-Pugh classification. Conclusions: Reduced mastication is associated with dynapenia markers in patients with cirrhosis. Further studies are needed to assess whether oral rehabilitation can change the curse of malnutrition in this population.

Associations of Serum Vitamin D with Sarcopenia in Patients with Chronic Liver Disease: A Population-Based Cross-Sectional Study

The association between vitamin D and sarcopenia in patients with chronic liver disease (CLD) has yet to be conclusively established, particularly in Western populations. We investigated the association between serum 25(OH)D levels and sarcopenia in adult CLD patients in the USA. We conducted a cross-sectional study using data from the National Health and Nutrition Examination Survey III. Weighted logistic regression was used to determine the association between sarcopenia and serum 25(OH)D in participants with CLD. CLD was defined as chronic hepatitis B or C, non-alcoholic fatty liver disease, alcohol-related liver disease, and other liver diseases. A serum 25(OH)D level of less than 75 nmol/L was defined as vitamin D insufficiency. This study included 1402 participants with CLD. The serum 25(OH)D concentration was significantly lower in the sarcopenia group (45.3 nmol/l) compared to the non-sarcopenia group (50.6 nmol/l). The prevalence of vitamin D insufficiency was as high as 91.3% in participants with CLD, and the proportion of vitamin D insufficiency was higher in those with sarcopenia. In the full multivariate model, each 10-nmol/L increase in 25(OH)D concentration was significantly associated with a decreased risk of sarcopenia (OR 0.89; 95%CI 0.79-0.99). Conversely, participants with insufficient vitamin D levels had a significantly increased risk of sarcopenia (OR, 2.07; 95% CI 1.08-4.00). Subgroup analyses suggested a sex difference in the association between vitamin D levels and sarcopenia, with a significant association only observed in females. Restricted cubic spline curves indicated a linear inverse association between serum 25(OH)D concentration and risk of sarcopenia in all participants and in females. Low serum 25(OH)D levels were significantly associated with an increased risk of sarcopenia in individuals with CLD, with the observed gender differences in this association warranting further validation in future studies.

Decreased Subcutaneous Adipose Tissue Correlates With Higher Portal Hypertension and Poor Survival in Patients With Cirrhosis: A Retrospective Binary-Center Study

INTRODUCTION

The aim of this study was to investigate the impact of hepatic venous portal gradient (HVPG) on body composition (BC) values and the prognostic value of BC value in cirrhotic patients.

METHODS

A total of 173 cirrhotic patients with HVPG and computed tomography scan were screened retrospectively from a binary-center database. Seven BC values, including skeletal muscle index, subcutaneous adipose tissue index (SATI), deep SATI (dSATI), superficial SATI (sSATI), visceral adipose tissue index, and ratio of visceral adipose tissue index and SATI along with skeletal muscle radiodensity, were analyzed. The correlation analyses and multiple linear regression were used to assess the impact of HVPG on BC values. The cumulative survival rate was assessed, and risk factors of survival were identified by competing risk analysis using Fine-Gray model.

RESULTS

Among 173 patients with a mean age of 53.7 ± 10.5 years, there were 111 male patients (64.2%) and 62 female patients (35.8%). In male patients, SATI, dSATI, and sSATI inversely correlated with HVPG, respectively (SATI: rho = -0.227; dSATI: rho = -0.229; sSATI: rho = -0.219; all P < 0.05), especially in patients aged 60 years or younger or with compensated cirrhosis; male patients with clinically significant portal hypertension had a lower SATI, dSATI, sSATI, and skeletal muscle radiodensity than those without clinically significant portal hypertension. After adjusted multiple linear models, male sex, Child-Pugh class B or C, and elevated HVPG contributed to decreased SATI. Multiple competing survival analysis showed a lower SATI (male: <38 cm 2 /m 2 ; female: <23 cm 2 /m 2 ), and Child-Pugh B or C predict mortality.

DISCUSSION

Decreased SATI, dSATI, and sSATI were more closely associated with increased HVPG. A lower SATI and Child-Pugh B or C predicted mortality.

Association of nutritional and inflammatory status with all-cause and cardiovascular mortality in adults with sarcopenia: Insights from NHANES

OBJECTIVE

Associations between scores on the advanced lung cancer inflammation index (ALI) and mortality among sarcopenic adults remains unknown. This study investigates the relationship between ALI and both all-cause and cardiovascular mortality among adults with sarcopenia.

METHODS

The study involved sarcopenic adults from the National Health and Nutrition Examination Survey (NHANES), conducted between 1999 and 2006 and 2011-2018. Mortality information was acquired from the National Death Index, which tracks deaths through to December 31, 2019. Weighted multivariable Cox proportional hazards regression was employed to calculate hazard ratios (HRs) for mortality in different models. Additionally, the restricted cubic spline (RCS) method was used to investigate non-linear associations. Subgroup analyses and sensitivity analyses were conducted to detect differences and examine the reliability of the findings.

RESULTS

This study included 2074 American adults with sarcopenia categorized into quartiles. 701 deaths occurred from all causes, with 236 linked to cardiovascular issues. Multivariate Cox regression models showed that those in the highest ALI quartile had a lower all-cause mortality rate than those in the lowest quartile (model 1: HR = 0.69, 95 % CI 0.55-0.87, P = 0.002; model 2: HR = 0.73, 95 % CI 0.56-0.94, P = 0.017). Likewise, those in the highest ALI quartile had a lower risk of death from cardiovascular causes (model 1: HR = 0.55, 95 % CI 0.36-0.85, P = 0.007; model 2: HR = 0.59, 95 % CI 0.37-0.95, P = 0.031). RCS results revealed an L-shaped correlation between ALI score and all-cause mortality.

CONCLUSIONS

A higher ALI score was strongly associated with lower rates of both all-cause and cardiovascular mortality among sarcopenic adults, particularly in the older population, males, smokers, and those with hypertension. This suggests that ALI may serve as a risk stratification tool.

Angiotensinogen inhibition concurrently mitigates alcohol-associated hepatic and muscle injury

AIMS

The organ communication mechanisms driven by alcohol-associated liver disease (ALD) remain inadequately understood. This study explores the endocrine roles of the hepatokine angiotensinogen (AGT) and the renin-angiotensin system (RAS) in ALD.

METHODS AND RESULTS

Hepatokine screening tests revealed that chronic-binge ethanol consumption upregulates hepatic AGT production, triggering downstream RAS activation. Hepatocyte-specific knockout of Agt (AGTΔHep) significantly alleviated ALD-induced liver injury. In organ screening between AGTflox/flox (AGTf/f) and AGTΔHep mice, skeletal muscle exhibited the most pronounced improvement in alcoholic myopathy (AM)-related phenotypes, including reduced muscle mass, enhanced oxidative stress, and mitochondrial dysfunction post-ethanol administration. Mechanistically, the renin-angiotensin axis transmits damaging signals from AGT to their membrane receptor AGTR1 in both hepatocytes and myocytes. Pharmacological inhibition of AGT, renin, and angiotensin-converting enzyme, as well as specific knockdown of Agtr1 in hepatocytes or myocytes, effectively attenuated both conditions. Activation of the counteractive axis of the RAS-AGTR1 pathway, involving Ang (1-7) and its membrane receptor MAS1, ameliorated the alcoholic injury of both the liver and muscle. Conversely, specific knockdown of Mas1 in hepatocytes and myocytes exacerbated these injuries.

CONCLUSIONS

Our work demonstrates that hepatokine AGT promotes ALD and AM through the activation of the RAS-AGTR1 axis and the inhibition of the Ang(1-7)-MAS1 axis, offering a foundation for concurrent therapeutic strategies for both diseases.

Sarcopenia and Frailty in Cirrhotic Patients: Evaluation of Prevalence and Risk Factors in a Single-Centre Cohort Study

Background and Objectives: Sarcopenia and frailty adversely affect morbidity and mortality in patients with liver cirrhosis. This study aimed to investigate the prevalence of sarcopenia and frailty in cirrhotic patients and to identify the contributing factors. Materials and Methods: This study was conducted in adult patients diagnosed with cirrhosis in a single-center cohort study who were under follow-up in the gastroenterology outpatient clinic. Patients were evaluated using the SARC-F questionnaire, FRAIL index, handgrip strength measurements, and various biochemical parameters. Results: Of the 100 patients included in the study, 58.7% were male, with a median age of 66.5 years. The prevalence of sarcopenia was 32%. Patients with sarcopenia had significantly lower body mass index (BMI) and higher model for end-stage liver disease (MELD)-Na and Child-Turcotte-Pugh (CTP) scores. According to the FRAIL scale, pre-frailty was highly prevalent among patients (60%). Significant negative correlations were observed between the SARC-F score and BMI, handgrip strength, albumin, vitamin D, and sodium levels. Conversely, significant positive correlations were identified between the SARC-F score and age, CTP score, MELD-Na score, bilirubin, AST, ALT, and ferritin levels. Conclusions: This study demonstrated a high prevalence of sarcopenia and frailty among cirrhotic patients. These findings warrants further investigation in longitudinal studies for hard clinical outcome and mortality.

Impact of GLP- 1 Receptor Agonist Therapy in Patients High Risk for Sarcopenia

PURPOSE OF REVIEW

Glucagon-like peptide- 1 receptor agonists (GLP- 1 RA) are a rapidly expanding class of medications used to treat many chronic diseases. This review explores factors that may contribute to accelerated muscle loss among higher-risk patient populations and describes tailored interventions to reduce the risk of accelerated sarcopenia and frailty.

RECENT FINDINGS

While GLP- 1 RA can result in total weight loss upwards of 25%, recent studies show that they can also lead to significant loss of lean body mass, reaching as high as 15-40% of total weight lost. This rapid and significant decline in muscle mass while taking GLP- 1 RA places certain patient populations already predisposed to sarcopenia at higher risk for muscle loss and adverse events. Currently, there is insufficient evidence delving into the impact of GLP- 1 RA on body composition among older adults, patients with chronic kidney disease, liver disease, and inflammatory bowel disease. However, research suggests that a high protein diet and resistance training may help prevent loss of muscle mass during GLP- 1 RA usage. A targeted and individualized nutrition and physical activity regimen should be instituted for each patient with a focus on optimizing protein intake and performing frequent resistance training in order to minimize loss of muscle mass while promoting the loss of fat mass. Future research should evaluate the impact of GLP- 1 RA on sarcopenia in high-risk patient populations.

Rifaximin-α use is associated with improved muscle mass in patients with cirrhosis

BACKGROUND

Sarcopaenia is associated with a two-fold higher mortality rate in patients with cirrhosis independent of liver disease severity. Few treatments for cirrhosis related sarcopaenia exist beyond optimal nutritional management.

AIM

To assess if rifaximin-α, a minimally absorbed antimicrobial used to manage hepatic encephalopathy (HE), may improve sarcopaenia in cirrhosis through its ammonia lowering and anti-inflammatory properties.

METHODS

This single-centre retrospective cohort study of patients with prior HE compared patients treated with lactulose alone to those on combination therapy with rifaximin-α. The primary outcome was a change in skeletal muscle area (SMA) as measured by computed tomography over two time points. Secondary outcomes included episodes of spontaneous bacterial peritonitis, variceal bleeding, and gastrointestinal Clostridium difficile infection.

RESULTS

Of the 142 patients included, 63 were on rifaximin-α [35% female, median age 57 (51, 62)], and 79 were on lactulose without rifaximin-α [20% female, median age 55 (51, 60)]. Univariate analysis for SMA found that male sex (P < 0.001), hepatocellular carcinoma presence (P = 0.024), and greater baseline body mass index (P = 0.001) were associated with improvement of SMA. Multivariate analysis that adjusted for baseline SMA was performed and found only use of rifaximin-α (P = 0.029) to be associated with improvement of SMA.

CONCLUSION

This study demonstrates a significant independent association between rifaximin-α therapy and muscle mass in patients with cirrhosis and HE. Prospective studies of rifaximin-α therapy examining its impact on sarcopenia are required to assess its potential therapeutic role in this cohort.

The prognostic value of sarcopenia in acute-on-chronic liver failure: a systematic review and meta-analysis

BACKGROUND

Sarcopenia is prevalent in patients with chronic liver diseases, especially in cirrhosis patients. While sarcopenia is identified as a predictor of mortality in cirrhosis, its influence on acute-on-chronic liver failure (ACLF) remains unclear. This systematic review with meta-analysis aimed to explore the prognostic value of sarcopenia in ACLF patients.

METHODS

A comprehensive online literature search was performed in Medline (via PubMed), Web of Science, Embase, and Cochrane Library, and eligible studies were screened according to the predetermined criteria. The quality of the included studies was assessed by using the revised Cochrane Collaboration Risk of Bias Tool for randomized-control studies and the Newcastle-Ottawa Quality Assessment Scale for observational studies. Available outcomes measured by odds ratio (OR), hazard ratio (HR), and risk ratio (RR) with a 95% confidence interval (CI) were extracted and further included in the meta-analysis. Stata (version 18.0) was used for all statistical analyses.

RESULTS

Nine studies were included in further analysis. The pooled prevalence of sarcopenia was 53.3% (95% CI: 53.26 - 71.23%). The presence of sarcopenia was positively associated with 28-day mortality (HR = 2.11, 95% CI: 1.50-2.95, p < 0.001, I2 = 0.0%; OR = 2.73, 95% CI: 1.37-5.42, p = 0.004, I2 = 0.0%), 90-day mortality (HR = 1.66, 95% CI: 1.13-2.46, p = 0.01, I2 = 72.3%), and overall mortality (HR = 1.81, 95% CI: 1.30-2.51, p < 0.01, I2 = 0.0%). When using continuous variables to describe sarcopenia, a 1-unit increase in these indicators was almost significantly related to reduced 90-day mortality (HR = 0.98, 95% CI: 0.95-1.00, p = 0.052, I2 = 0.0%) and significantly associated with lower 1-year post-transplantation mortality (HR = 0.91, 95% CI: 0.85-0.98, p = 0.012, I2 = 32.7%).

CONCLUSION

Current evidence illustrates that sarcopenia is an unfavorable factor for both short- and long-term prognosis. More studies are needed to validate these findings in the future.

Imaging-based assessment of muscles and malnutrition predict prognosis in patients with primary hepatocellular carcinoma

BACKGROUND

The significance of imaging-based assessment of muscles and malnutrition in patients with primary hepatocellular carcinoma (HCC) remains unclear. This study aimed to elucidate the prognostic role of the combination of Low Muscle Volume and Value (LMVV) and malnutrition.

METHODS

A total of 714 Child-Pugh grade A/ B patients with first-diagnosed HCC were enrolled, and analyzed factors associated with overall survival. LMVV was defined using psoas muscle mass index and computed tomography values of multifidus muscle at the level of the third lumbar vertebra. We used hypoalbuminemia, Child-Pugh grade B, Subjective Global Assessment (SGA) grade B/C, and Royal Free Hospital Nutrition Prioritizing Tool (RFH-NPT) score > 2 as malnutrition factors in this study.

RESULTS

At baseline, 29% showed LMVV, and 59% met one or more of the malnutrition criteria. No items meeting the criteria of LMVV and malnutrition was observed in 41%, 1 of them was found in 29%, and both were found in 29%. The number of items meeting criteria was an independent factor for a shorter survival. The frequency of liver-related deaths did not differ by presence of LMVV alone, while it was associated with malnutrition. In contrast, the incidence of other types of deaths was influenced by LMVV and malnutrition.

CONCLUSIONS

The combination of LMVV and malnutrition is a prognostic factor in patients with primary HCC.

New insights into biomarkers and risk stratification to predict hepatocellular cancer

Hepatocellular carcinoma (HCC) is the third major cause of cancer death worldwide, with more than a doubling of incidence over the past two decades in the United States. Yet, the survival rate remains less than 20%, often due to late diagnosis at advanced stages. Current HCC screening approaches are serum alpha-fetoprotein (AFP) testing and ultrasound (US) of cirrhotic patients. However, these remain suboptimal, particularly in the setting of underlying obesity and metabolic dysfunction-associated steatotic liver disease/steatohepatitis (MASLD/MASH), which are also rising in incidence. Therefore, there is an urgent need for novel biomarkers that can stratify risk and predict early diagnosis of HCC, which is curable. Advances in liver cancer biology, multi-omics technologies, artificial intelligence, and precision algorithms have facilitated the development of promising candidates, with several emerging from completed phase 2 and 3 clinical trials. This review highlights the performance of these novel biomarkers and algorithms from a mechanistic perspective and provides new insight into how pathological processes can be detected through blood-based biomarkers. Through human studies compiled with animal models and mechanistic insight in pathways such as the TGF-β pathway, the biological progression from chronic liver disease to cirrhosis and HCC can be delineated. This integrated approach with new biomarkers merit further validation to refine HCC screening and improve early detection and risk stratification.

Evaluating sarcopenia and nutritional status in outpatients with liver cirrhosis: concordance of diagnostic methods

Introduction

Introduction and objectives: malnutrition and sarcopenia are prevalent in individuals with cirrhosis, but their diagnosis remains challenging due to limited access to suitable methods across different levels of healthcare. This study aimed to identify the most effective method for diagnosing sarcopenia in outpatients with liver cirrhosis and to evaluate the concordance between subjective and objective diagnostic methods. Patients and methods: patients aged ≥ 18 years with a diagnosis of cirrhosis (regardless of etiology) under outpatient care were included. Exclusion criteria were: a) neoplasia, b) acute liver failure, c) pregnancy/lactation, d) HIV infection, e) special situations requiring liver transplantation, and f) history of organ failure. Nutritional and sarcopenia assessments used subjective methods, including the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT), SARC-F, SARC-Calf, and RFH-Global Assessment (RFH-GA); and objective methods, including anthropometry, handgrip strength (HGS), the sit-and-stand test (15s), and appendicular skeletal muscle mass index (ASMI) by Dual-Energy X-ray Absorptiometry (DXA). Concordance between ASMI and traditional methods was analyzed. Significance was set at p < 0.05. Results: a total of 45 patients were analyzed, with alcoholic liver disease being the most frequent etiology (44.4 %). The sit-and-stand test (15s) combined with muscle depletion by DXA diagnosed the most cases of sarcopenia (42.2 %). Moderate agreement was found between muscle depletion and isolated calf circumference (CC) (κ = 0.581; p < 0.001). Conclusions: our study suggests excluding SARC-F and SARC-CalF from sarcopenia screening in outpatients with cirrhosis. While ASMI remains the most reliable diagnostic method, CC may serve as a feasible alternative when DXA is unavailable.

The impact of immature granulocytes on the outcome of patients with decompensated cirrhosis

BACKGROUND

Higher immature granulocyte levels have a predictive role in several clinical conditions, although data concerning cirrhosis are scarce. Reduced muscle mass is a known factor affecting the outcome of these patients. The aim of the study was to evaluate the association of immature granulocytes with muscle mass and their role in predicting the outcome (survival, death or liver transplantation) in patients with stable decompensated cirrhosis.

METHODS

We prospectively studied 210 patients with decompensated cirrhosis awaiting liver transplantation. Their clinical and laboratory characteristics were recorded, including complete blood count with immature granulocyte count and immature granulocyte percentage. The severity of liver disease was evaluated by estimating the Child-Turcotte-Pugh and MELD-sodium scores. Dual energy X-ray absorptiometry was used to quantify the total and regional lean mass, while mid-arm muscle circumference was used for the evaluation of upper limb muscle mass.

RESULTS

Immature granulocyte percentage was proved to be the only factor independently associated with transplant-free survival (Hazard Ratio: 1.98, 95% confidence interval [1.03-3.81], p = .04). Stratification of our cohort based on the best discriminative cut-off values of immature granulocyte count and percentage revealed significant differences in the outcome based on Kaplan-Meier curves, while immature granulocyte count and percentage were significantly associated with parameters of body composition.

CONCLUSIONS

Higher immature granulocyte count and percentage have a significant prognostic role and are associated with worse outcome in patients with stable decompensated cirrhosis.

Prognostic nutritional index predicts survival in intermediate and advanced hepatocellular carcinoma treated with hepatic arterial infusion chemotherapy combined with PD-(L)1 inhibitors and molecular targeted therapies

BACKGROUND

This study aimed to evaluate the predictive efficacy of the prognostic nutritional index (PNI) in patients with intermediate and advanced hepatocellular carcinoma (HCC) treated with a regimen consisting of hepatic arterial infusion chemotherapy (HAIC), PD-(L)1 inhibitors, and molecular targeted therapies (MTTs).

METHODS

A retrospective analysis was performed on the data of 88 HCC patients received triple therapy between January 2020 and August 2022 at three medical centers. Univariate and multivariable analyses were conducted to assess the relationship between PNI and survival outcomes.

RESULTS

The median follow-up was 11.0 months (IQR: 8.0-17.0). The PNI cut-off value of 38.6 was determined using receiver operating characteristics (ROC) analysis. The median overall survival (OS) durations were 29.0 and 8.0 months in the high-PNI (≥ 38.6) and low-PNI (≤ 38.6) groups, respectively (HR = 0.306, 95% CI, 0.170-0.552, P < 0.001), and the median progression-free survival (PFS) durations were16.0 and 6.0 months, respectively (HR = 0.521, 95% CI, 0.303-0.896, P = 0.014). A higher complete response rate was observed in the high-PNI group (17.5% vs. 3.2%, P = 0.033). The univariate and multivariable analyses revealed that a PNI of ≥ 38.6 had an independent influence on both median OS (HR = 0.296; 95% CI, 0.159-0.551, P < 0.001) and median PFS (HR = 0.560; 95% CI, 0.318-0.987, P = 0.045).

CONCLUSION

The PNI is an objective and convenient tool that can potentially predict the prognosis of patients treated with HAIC-based triple therapy.

Causal relationships of circulating amino acids with sarcopenia-related traits: A bidirectional Mendelian randomization study

BACKGROUND AND AIM

Recent studies have indicated a correlation between certain Amino acids (AAs) and sarcopenia. However, the exact causal relationship among these associations is still unclear. This study aims to elucidate the causal relationships between 20 types of AAs and the phenotypic characteristics associated with sarcopenia through Mendelian randomization (MR) analysis.

METHODS AND RESULTS

This MR study employed single nucleotide polymorphisms (SNPs) that were significantly associated with both AAs and the traits of sarcopenia as instrumental variables (IVs). The main method for estimating causal effects was the inverse-variance weighted (IVW) approach. To ensure the robustness of the findings, additional methods such as weighted median, weighted mode, and MR Egger regression were used. Sensitivity analyses included heterogeneity and pleiotropy tests. In this research, we discovered potential causal relationships between AAs and traits associated with sarcopenia. We not only found that AAs previously studied, such as Glutamine, Tyrosine, Glycine, and branched-chain amino acids, play positive roles in muscle metabolism. Additionally, our study identified the role of AAs previously neglected or not considered in earlier research, such as Alanine, Lysine, Cysteine, and Methionine, which exert potential effects on muscle metabolism and offer considerable research potential and value.

CONCLUSIONS

This MR study clarified the reciprocal effects between circulating levels of AAs and sarcopenia-related traits. These results indicate that AAs may be used as biomarkers for diagnosing sarcopenia or as intervention targets for its treatment in clinical practice.

An Overview of Sarcopenia: Focusing on Nutritional Treatment Approaches

Sarcopenia is a syndrome characterized by the progressive and generalized loss of skeletal muscle mass and strength. This condition is associated with physical disability, decreased quality of life, and increased mortality. Therefore, reducing the prevalence of sarcopenia could significantly lower healthcare costs. Sarcopenia can be classified into primary and secondary sarcopenia. The former is related to aging and begins after the fourth decade of life; after that, there is a muscle loss of around 8% per decade until age 70 years, which subsequently increases to 15% per decade. On the other hand, secondary sarcopenia can affect all individuals and may result from various factors including physical inactivity, malnutrition, endocrine disorders, neurodegenerative diseases, inflammation, and cachexia. Understanding the multiple mechanisms involved in the onset and progression of sarcopenia allows for us to develop strategies that can prevent, treat, or at least mitigate muscle loss caused by increased protein breakdown. One potential treatment of sarcopenia is based on nutritional interventions, including adequate caloric and protein intake and specific nutrients that support muscle health. Such nutrients include natural food rich in whey protein and omega-3 fatty acids as well as nutritional supplements like branched-chain amino acids, β-hydroxy-β-methylbutyrate, and vitamin D along with food for special medical purposes. It is important to emphasize that physical exercises, especially resistance training, not only promote muscle protein synthesis on their own but also work synergistically with nutritional strategies to enhance their effectiveness.

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) Impacts Long-Term Outcomes After Curative-Intent Surgery for Hepatocellular Carcinoma

BACKGROUND

Curative surgery for hepatocellular carcinoma (HCC) includes liver resection (LR) and orthotopic liver transplantation (OLT). Due to the obesity epidemic, metabolic dysfunction-associated steatotic liver disease (MASLD) is a frequent HCC aetiology that often coincides with increased alcohol consumption, termed MetALD, or even alcohol-associated liver disease (ALD).

METHODS

Patients undergoing LR or OLT for HCC at Charité-Universitätsmedizin Berlin (2010-2020) were included in this retrospective cohort study investigating disease aetiology, time to recurrence (TTR), overall survival (OS) and CT-based body composition.

RESULTS

Out of 579 patients with HCC, 417 underwent LR and 162 OLT. Tumour aetiologies were viral n = 191 (33.0%), MASLD n = 158 (27.3%), MetALD n = 51 (8.8%), ALD n = 68 (11.7%) and other/cryptogenic n = 111 (19.2%). Patients with MASLD and MetALD had more intramuscular (p < 0.001, p = 0.015) and visceral fat (both p < 0.001) than patients with non-metabolic dysfunction aetiologies. Patients with MASLD-HCC had comparable TTR (median 26 months, [95% CI: 23-31] vs. 30 months [95% CI: 4-57], p = 0.425) but shorter OS than patients with other HCC aetiologies (63 months [95% CI: 42-84] vs. 80 months [95% CI: 60-100], hazard ratio: 1.53 [95% CI: 1.050-2.229], p = 0.026) after LR. Multivariate analysis confirmed MASLD aetiology, portal vein thrombosis and MELD score ≥ 10 as independent prognostic factors for OS in LR (adjusted p = 0.021,p < 0.001,p = 0.003), even after excluding in-hospital mortality (adjusted p = 0.016,p = 0.002,p = 0.002). Causes of death were similar in MASLD and non-MASLD aetiology.

CONCLUSIONS

Patients with HCC undergoing LR and meeting the new MASLD criteria have significantly shorter OS. This study provides empirical prognostic evidence for the novel MASLD/MetALD classification in a large European cohort of patients undergoing curative-intent HCC therapy.

Association between sarcopenia and the prevalence of gallstone in US adults: a cross-sectional analysis of NHANES

BACKGROUD

Gallstones are a common disease that imposes a significant burden on public health resources. Sarcopenia is an age-related condition characterized by a decline in muscle mass, strength, and function. However, its relationship with gallstones remains unclear.

METHODS

This cross-sectional study included 2,167 US adults from the National Health and Nutrition Examination Survey. We used the multivariable logistic regression models and restricted cubic spline regression to to assess the relationship between sarcopenia and gallstones. Additionally, subgroup analyses and propensity score matching (PSM) were conducted to account for potential confounding factors.

RESULTS

We found a significant negative association between the sarcopenia index and the prevalence of gallstones (OR: 0.253, 95% CI: 0.132-0.471, P < 0.001). In Model 4, which integrated all covariates, sarcopenia was associated with approximately a 100% increased prevalence of gallstones compared to non-sarcopenia patients (OR: 1.995, 95% CI: 1.340-2.948, P < 0.001). The results of PSM also confirmed the association between sarcopenia and gallstones (OR: 1.982, 95% CI: 1.217-3.285, P = 0.007). Notably, this association was more pronounced in subgroups including females, non-Hispanic whites, married individuals, and higher education level.

CONCLUSION

In summary, our findings suggest a positive association between sarcopenia and the prevalence of gallstones in US adults. This suggests that we should increase the emphasis on gallstone disease screening in sarcopenia patients. However, this finding needs to be validated through further large-scale prospective studies.

Hepatic cirrhosis and decompensation: Key indicators for predicting mortality risk

Liver cirrhosis represents the final stage of liver diseases. The transition from the compensated to the decompensated form is a critical phase, as it is associated with a negative impact on patient prognosis. Therefore, having a tool to identify patients at higher risk of complications and mortality is an ideal goal. Currently, the validated scores for this purpose are the model for end-stage liver disease score and the Child-Pugh score. However, these scores have limitations, as they do not account for other factors associated with liver cirrhosis that are equally relevant from a prognostic perspective. Among these, alterations in body composition, particularly sarcopenia, increase the risk of mortality and should therefore be considered in the comprehensive assessment of patients with liver cirrhosis.

Prognostic significance of skeletal muscle mass in patients with alcohol-related cirrhosis

AIM

This study aimed to assess the prognostic significance of hand grip strength (HGS) and skeletal muscle mass index (SMI) in patients with alcohol-related cirrhosis.

METHODS

535 patients with liver cirrhosis (LC) were assessed for HGS and computed tomography (CT)-based SMI. They were categorized into alcohol-related liver disease (ARLD; n = 226), metabolic dysfunction-associated steatohepatitis (MASH; n = 119), and virus-related cirrhosis (VC, n = 190) groups.

RESULTS

Overall prevalence of sarcopenia was 16.4%, 11.8%, and 27.4% in the ARLD, MASH, and VC groups, respectively. Three factors including low SMI, low albumin (Alb) levels, low sodium (Na) levels, and two factors including low HGS and low Alb levels, and three factors including the presence of ascites, low cholinesterase (Ch-E) levels, and low HGS were identified as prognostic factors for mortality in the ARLD, MASH and VC groups, respectively. In the ARLD group, overall survival (OS) was significantly lower in low SMI + low HGS and normal HGS + low SMI (pre-sarcopenia) than in normal SMI and HGS. OS was significantly lower in sarcopenia than in normal SMI + low HGS (dynapenia). In the MASH group, OS was significantly lower in sarcopenia and dynapenia than in normal SMI and HGS. In the VC group, OS was significantly lower in sarcopenia and dynapenia than in normal SMI and HGS; OS was significantly lower in sarcopenia than in pre-sarcopenia.

CONCLUSIONS

In the ARLD group, SMI could serve as a more powerful predictor of survival than HGS.

Nutritional Approach to Diabetic Sarcopenia: A Comprehensive Review

PURPOSE OF THE REVIEW

The aim of this review is to discuss and evaluate diabetic sarcopenia (DS) and its relationship with nutrition by discussing the mechanisms of diabetic sarcopenia in detail and comprehensively reviewing the literature.

RECENT FINDINGS

Type 2 diabetes (T2DM) affects approximately 25% of people aged 50 years and over and indicates a significant the cost of health for the elderly. Nutrition is an important part of these treatment approaches, and in this review, the literature was comprehensively reviewed, focusing on understanding the mechanisms of DS and discussing its relationship with nutrition. A comprehensive search was conducted on Web of Science, Google Scholar, Scopus, Science Direct, and PubMed from inception up to July 2024. The aim of nutritional treatment for DS is to improve muscle mass, muscle strength and physical performance while improving diabetes-related metabolic risk and glucose levels. In this context, it is important to determine energy intake in individuals with DS according to calorie intake exceeding 30 kcal/kg. For these individuals, a protein intake of at least 1-1.2 g/kg/day is recommended, with an emphasis on the number and timing of meals and a nutritional pattern rich in branched chain amino acids (BCAA). In addition, it is important to adopt a diet rich in antioxidants and to choose diet patterns that contain sufficient levels of macro and micronutrients. The Mediterranean diet model can be a good diet option for individuals with DS. Comprehensive studies in this field are needed so that clinicians can make specific dietary recommendations for DS.

Cachexia is an independent predictor of mortality in patients with cirrhosis

AIM

Cachexia is a systemic response syndrome characterized by disabling wasting during disease progression. This study aimed to elucidate factors associated with cachexia in patients with cirrhosis and to examine the impact of cachexia on patient survival.

METHODS

This multicenter retrospective cohort study included patients with cirrhosis admitted to two distinct institutes in Japan. Cachexia was diagnosed according to the criteria proposed by the Asian Working Group for Cachexia. Factors associated with cachexia and the prognostic impact of cachexia were assessed using logistic regression and Cox proportional hazards regression, respectively.

RESULTS

Of the 723 patients enrolled (median [interquartile range] age, 71 [64-77] years; 456 [63%] were male; and 390 [54%] had viral hepatitis), 200 (28%) met the criteria for cachexia diagnosis, with the prevalence increasing with Child-Pugh class from A (17%) to B (40%) and C (66%). Multivariable logistic regression analysis revealed that age and indices of liver function reserve, including Child-Pugh score, were associated with cachexia, whereas sex, etiology of cirrhosis, and complications with hepatocellular carcinoma (HCC) were not. During a median follow-up period of 3.2 years, 264 (37%) patients died. Multivariable Cox regression analyses showed that cachexia was independently associated with increased mortality (adjusted hazard ratio, 1.59; 95% confidence interval, 1.43-1.77), along with factors related to liver function, HCC, and alcohol-associated liver disease as the etiology.

CONCLUSIONS

Cachexia is associated with poor liver function in patients with cirrhosis and is an independent prognostic factor.

Hepatic encephalopathy: risk identification and prophylaxis approaches

Hepatic encephalopathy (HE) is a debilitating neurological condition associated with cirrhosis, characterized by cognitive impairment ranging from minimal to overt symptoms. It significantly impacts patients' quality of life and substantially burdens healthcare systems. This review examines current prophylactic strategies for HE, focusing on established treatments, emerging therapies, and predictive tools to identify high-risk patients. Traditional treatments such as lactulose and rifaximin remain the cornerstone of HE management, effectively reducing ammonia levels and preventing recurrence. However, novel approaches like L-ornithine L-aspartate, albumin infusions, and antioxidants like resveratrol show promise in further improving outcomes by addressing underlying pathophysiological mechanisms, including systemic inflammation and gut dysbiosis. Developing predictive models, such as the AMMON-OHE score and clinical-genetic risk assessments, enhances the ability to tailor preventive interventions to individual patient profiles. These advancements are crucial in mitigating the incidence of overt HE, reducing hospital admissions, and improving patient survival rates. The future of HE management lies in personalized medicine, targeting specific inflammatory and metabolic pathways, with the potential integration of genetic manipulation. Continued research is essential to refine these strategies, ultimately aiming to improve the prognosis and quality of life for cirrhotic patients at risk of HE.

PRR14 mediates mechanotransduction and regulates myofiber identity via MEF2C in skeletal muscle

Skeletal muscle is a crucial tissue for physical activity and energy metabolism. Muscle atrophy, characterized by the loss of muscle mass and strength, contributes to adverse outcomes among individuals. This study elucidated the involvement of the nuclear lamina component PRR14 in transmitting mechanical signals and mediating the impact of exercise on skeletal muscle. The expression of PRR14 demonstrated a positive correlation with exercise, while a decline in adult skeletal muscle is evident in disuse muscle conditions. Genetically, multiple single nucleotide polymorphisms (SNPs) within PRR14's genomic locus were linked with muscle mass and function. Specific knockout (KO) of skeletal muscle Prr14 in mice lead to muscle atrophy, validating the genetic association. By employing biochemical analysis and high-throughput sequencing techniques, including transcriptome profile and epigenome investigations such as Cleavage Under Targets and Tagmentation sequencing (CUT&Tag-seq) and Transposase-Accessible Chromatin sequencing (ATAC-seq), we discovered that PRR14's deficiency altered chromatin structure, regulated MEF2C's activity, and disrupted myofiber identity maintenance, ultimately causing muscle atrophy. Our finding highlights the crucial role of PRR14 in mechanotransduction and epigenetic regulation, offering new therapeutic avenues for skeletal muscle pathologies related to these mechanisms.

The clinical relevance of acute-on-chronic liver failure in medical procedures: Endoscopy, interventions and surgery

Acute-on-chronic liver failure (ACLF) is a specific, but complex and multifactorial form of acute decompensation (AD) of cirrhosis and is characterized by an extraordinary dynamic natural course, rapidly evolving organ failure and high short-term mortality. In daily clinical practice, patients with liver cirrhosis and decompensation have indications for different medical procedures such as endoscopies, interventional treatments like transjugular intrahepatic portosystemic shunt (TIPS) or even surgical procedures. In these situations, clinicians often need to balance the expected benefits of such procedures with the risks of causing acute decompensation or ACLF. This review summarizes the evidence of medical procedures and their role in precipitating or preventing ACLF and highlights the aspects to consider during patient selection.

Dynamic skeletal muscle loss and its predictive role on 90-day mortality in patients with acute-on-chronic liver failure

Background

Low skeletal muscle mass is an independent risk factor for increased mortality in patients with acute-on-chronic liver failure (ACLF). However, no study has evaluated the temporal changes in muscle mass during the course of ACLF. Therefore, this study aimed to investigate the dynamic changes in muscle mass and their prognostic role in patients with ACLF.

Methods

A retrospective analysis was conducted on consecutive patients with ACLF who underwent two or more abdominal computed tomography examinations within 90 days of admission. The percentage change rates of the skeletal muscle index at the third lumbar vertebra (L3-SMI) were calculated as (L3-SMIfinal - L3-SMIinitial)/(L3-SMIinitial) × 100%.

Results

A total of 154 patients with ACLF were included. During the course of ACLF, the percentage change rates of L3-SMI at 2-7, 8-14, 15-30, 31-60, and 61-90 days were - 0.83 ± 4.43, -3.76 ± 4.40, -7.30 ± 5.89, -10.10 ± 7.45, and - 5.53 ± 9.26, respectively. Significant reductions in L3-SMI were noted in patients with severe conditions compared to other patients at 2-7 days and 15-30 days. Moreover, the rate of decrease in L3-SMI in patients with a lower respiratory quotient (RQ) was significantly greater than that in patients with a normal RQ at 2-7 days and 15-30 days. Additionally, high muscle loss (HR 2.059; 95% CI 1.122-3.780, p = 0.020), rather than pre-existing sarcopenia (HR 1.430; 95% CI 0.724-2.826, p = 0.303) at baseline, was independently associated with 90-day mortality.

Conclusion

Deterioration in muscle mass is associated with disease severity and poor nutritional status and serves as a more effective predictor of adverse short-term outcomes in patients with ACLF. These findings underscore the importance of dynamic evaluation of muscle loss and emphasize the necessity of reversing muscle loss in patients with ACLF.

Relationship between Sarcopenia and minimal hepatic encephalopathy in patients with cirrhosis: a prospective observational study

BACKGROUND

Sarcopenia, characterized by loss of muscle mass and function, has gained importance in the evaluation of cirrhotic patients. Evidence suggests its role in adverse clinical outcomes, including minimal hepatic encephalopathy (MHE). This study aimed to investigate the association between sarcopenia and MHE in patients with cirrhosis.

METHODS

We prospectively enrolled outpatients with cirrhosis to assess sarcopenia using the 2019 criteria from the Asian Working Group for Sarcopenia. MHE was diagnosed through the Psychometric Hepatic Encephalopathy Score.

RESULTS

Of the 210 cirrhotic patients (57.1% male, mean age 62.7 ± 9.6 years), 54 (25.7%) had sarcopenia, with 26 (12.3%) classified as severe. Thirty-seven patients (17.6%) were diagnosed with MHE. Sarcopenia prevalence was significantly higher in patients with MHE compared to those without MHE (45.9% vs. 21.4%). MHE was significantly associated with age, education level, Mini-Mental State Examination score, and a history of hepatic decompensation. No significant associations were found regarding gender, body mass index, comorbidities, sleep quality, and the etiology of cirrhosis. Multivariable logistic regression showed that MHE was significantly associated with age (adjusted odds ratio [aOR] 1.08, 95% CI 1.02-1.13), sarcopenia (aOR 3.29, 95% CI 1.44-7.50), history of overt hepatic encephalopathy (aOR 7.40, 95% CI 1.20-45.56), and variceal bleeding (aOR 3.13, 95% CI 1.38-7.10). Severe sarcopenia was also independently associated with MHE (aOR 3.64, 95% CI 1.32-10.05).

CONCLUSIONS

Sarcopenia is prevalent in cirrhotic patients and is associated with an increased risk of MHE. Our findings emphasize the importance of assessing sarcopenia to potentially mitigate MHE risk in managing patients with cirrhosis.

The association between eight complete blood count-derived inflammatory markers and muscle health

Background

Most studies have evaluated sarcopenia and muscle health solely based on muscle mass. This study comprehensively examined the associations between eight inflammatory indicators and muscle mass and strength, with the aim of identifying an indicator capable of evaluating muscle health across multiple dimensions.

Methods

This study included 10,440 participants from the National Health and Nutrition Examination Survey (NHANES, 2011-2018) and 5,384 participants from NHANES (2011-2014). Multivariate logistic regression, smooth curve fitting, restricted cubic spline (RCS) analysis, subgroup analysis, and Spearman's correlation were used to comprehensively assess the associations between the eight inflammatory indicators and muscle mass and strength. Receiver operating characteristic (ROC) curves were used to compare the predictive abilities of the different indices for low muscle mass and muscle strength. Additionally, NHANES data were cross-validated with data from 554 patients at our hospital to evaluate the ability of the systemic immune inflammatory index (SII) to distinguish between low muscle mass and strength.

Results

After controlling for all potential confounding factors, multiple logistic regression analysis revealed that apart from the platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), and derived NLR (dNLR), the neutrophil-to-monocyte-plus-lymphocyte ratio (NMLR), neutrophil-to-lymphocyte ratio (NLR), SII, systemic inflammation response index (SIRI), and pan-immune-inflammation value (PIV) were significantly negatively correlated with muscle mass and strength. However, NMLR and NLR were significantly associated with changes in muscle mass only in Q4 (P < 0.05). In the stratified analysis by body mass index (BMI), only the SII, NLR, and NMLR were unaffected by BMI. In the cross-validation, the predictive performance of the SII for low muscle mass [area under the curve (AUC) = 0.699, 0.677, and 0.685] and low muscle strength (AUC = 0.857, 0.849, and 0.840) demonstrated a good reference value. RCS and smooth curve fitting analyses indicated that most inflammatory markers were linearly correlated with muscle health (P < 0.05).

Conclusion

Compared with other inflammatory markers (e.g., PIV and dNLR), the SII demonstrated a more robust predictive ability, was less influence by covariates, and exhibited high generalization performance in internal and external validation. SII may be crucial in identifying "hidden sarcopenia" and the early stages of muscle functional decline.

Sarcopenia As a Predictor of Survival and Complications of Patients With Cirrhosis After Liver Transplantation: A Systematic Review and Meta-Analysis

INTRODUCTION

This systematic review/meta-analysis evaluated the impact of sarcopenia in patients with cirrhosis before liver transplantation (LT) on outcomes after LT.

METHODS

A systematic search was conducted in six medical databases until February 2022. The primary outcome was overall mortality after LT, while several secondary outcomes including liver graft survival and rejection, the need for transfusions, the length of the intensive care unit (ICU) and hospital stay, and surgical complications were evaluated. Sub-group analyses and meta-regression analyses were also performed.

RESULTS

Fifty-three studies were evaluated in the systematic review, of which 30, including 5875 patients, were included in the meta-analysis. All studies included were cohort studies of good/high quality on the Newcastle-Ottawa scale (NOS), while in our analysis no publication bias was found, although there was substantial heterogeneity between the studies. Muscle mass was assessed using skeletal muscle index (SMI) in 14 studies, psoas muscle area (PMA) in seven studies, and psoas muscle index (PMI) in four studies. The prevalence of pre-LT sarcopenia ranged from 14.7% to 88.3%. Pre-LT sarcopenia was significantly associated with post-LT mortality (Relative Risk [RR] = 1.84, 95% CI:1.41,2.39), as well as with a high risk of infections post-LT, surgical complications, fresh frozen plasma (FFP) transfusions, and ICU length of stay (LOS).

CONCLUSIONS

Pre-LT sarcopenia in patients with cirrhosis is a strong risk factor for clinically meaningful adverse outcomes after LT. Assessment may help identify patients at the highest risk for poor outcomes who may benefit from targeted interventions.

Initial participant perspectives about participating in an online, semi-supervised, cirrhosis-specific nutrition and exercise intervention

OBJECTIVES

In chronic diseases, there have been issues with low levels of participant adherence and retention during well-supported lifestyle behaviour change interventional studies. Theoretically informed, the objective was to explore the types of challenges participants are experiencing to inform future designs.

DESIGN

We conducted an exploratory descriptive study in an adult cirrhosis population after the first 4-6 weeks of a 12-week semi-supervised nutrition and exercise online program.

METHODS

Participants in the parent feasibility study, assessing the nutrition and exercise intervention (Heal-Me), were eligible for this nested study. Heal-Me is a multimodal program that is tailorable to a participant's abilities through regular interaction with the study's registered dietician and exercise specialist. Interviews (~60 min) with participants were recorded then analysed descriptively, guided by the capability, opportunity and motivational behaviour change model.

RESULTS

The 20 participants preferred the expert-led group online nutrition and exercise classes over independent activities such as protein tracking and the exercise videos. Social gamification (e.g., weekly polls on favourite things like movies or sports teams) contributed to the group experience. All except one person required program tailoring to address preferences, abilities and new onset health events. Findings led to the inclusion of 4 behaviour change techniques to the initial 17, whereas 2 others were expanded.

CONCLUSIONS

While program tailoring, awareness of cirrhosis nutrition and regular interactions with staff influenced participant retention and adherence in the first 4-6 weeks of the online program.

Skeletal Muscle 31P MR Spectroscopy Surpasses CT in Predicting Patient Survival After Liver Transplantation

BACKGROUND

Skeletal muscle alterations are associated with higher mortality and morbidity in patients with liver cirrhosis. Assessing these changes seems to be a promising method for identifying patients at a high risk of poor outcomes following liver transplantation (LT). This is particularly important given the current global shortage of organ donors. However, evidence of the impact of these alterations on the prognosis of patients undergoing LT is inconclusive. The aim of our prospective study was to evaluate the impact of skeletal muscle changes, reflected in sarcopenia, myosteatosis and metabolic changes in the calf muscles, on perioperative outcomes and long-term survival after LT. We also sought to determine the posttransplant evolution of the resting muscle metabolism.

METHODS

We examined 134 adult LT candidates. Of these, 105 underwent LT. Sarcopenia and myosteatosis were diagnosed by measuring the skeletal muscle index and mean psoas muscle radiation attenuation, respectively, which were obtained from computed tomography (CT) scans taken during pretransplant assessment. Additionally, patients underwent 31P MR spectroscopy (MRS) of the calf muscles at rest before LT and 6, 12 and 24 months thereafter. The median follow-up was 6 years.

RESULTS

Patients with abnormal 31P MRS results and CT-diagnosed myosteatosis prior to LT had significantly worse long-term survival after LT (hazard ratio (HR), 3.36; 95% confidence interval (CI), 1.48-7.60; p = 0.0021 and HR, 2.58; 95% CI, 1.06-6.29; p = 0.03, respectively). Multivariable analysis showed that abnormal 31P MR spectra (HR, 3.40; 95% CI, 1.50-7.71; p = 0.003) were a better predictor of worse long-term survival after LT than myosteatosis (HR, 2.78; 95% CI, 1.14-6.78; p = 0.025). Patients with abnormal 31P MR spectra had higher blood loss during LT (p = 0.038), required a higher number of red blood cell transfusions (p = 0.006) and stayed longer in ICU (p = 0.041) and hospital (p = 0.007). Myosteatosis was associated with more revision surgeries following LT (p = 0.038) and a higher number of received red blood cell transfusion units (p = 0.002). Sarcopenia had no significant effect on posttransplant patient survival. An improvement in the resting metabolism of the calf muscles was observed at 12 and 24 months after LT.

CONCLUSIONS

Abnormal 31P MRS results of calf muscles were superior to CT-based diagnosis of myosteatosis and sarcopenia in predicting perioperative complications and long-term survival after LT. Resting muscle metabolism normalized 1 year after LT in most recipients.

The Role of Myokines in Liver Diseases

Myokine is a general term for hormones, peptides, and other substances secreted by skeletal muscle. Myokine has attracted much attention in recent years as a key substance for understanding the mechanism of "exercise and health". Skeletal muscle accounts for about 40% of the total human weight and is now recognized as an endocrine organ that produces myokines, which have physiological activity. Representative myokines include IL-6, myostatin, irisin, brain-derived neurotropic factor, fibroblast growth factor-21, and decorin. On the other hand, sarcopenia, defined by quantitative and qualitative loss of skeletal muscle, is a condition that has received much attention in recent years because of its close correlation with prognosis. In patients with chronic liver disease (CLD), sarcopenia is a common complication. Mechanisms underlying sarcopenia in CLD patients have been reported to involve protein-energy malnutrition, which is characteristic of patients with cirrhosis, signaling involved in protein synthesis and degradation, myokines such as myostatin and decorin, the ubiquitin-proteasome pathway, sex hormones such as testosterone, dysbiosis, and insulin resistance, etc., in addition to aging. Each of these pathological conditions is thought to be intricately related to each other, leading to sarcopenia. This review will summarize the relationship between CLD and myokines.

Relationship Between Body Mass Index and Low Skeletal Muscle Mass in Adults Based on NHANES 2011-2018

Sarcopenia, a syndrome characterized by declining muscle mass and function, is associated with various adverse health outcomes. While body mass index (BMI) is a fundamental health indicator, its relationship with sarcopenia is complex and remains inadequately explored. Low BMI has been linked to muscle loss, but the role of other demographic and clinical factors in this relationship is unclear. This cross-sectional study analyzed data from the NHANES 2011-2018 cohort, including 7,455 adults aged ≥ 20 years. Low muscle mass was diagnosed based on appendicular skeletal muscle mass using DXA criteria. BMI was categorized into quartiles for analysis. Weighted multivariable logistic regression assessed associations between BMI and low muscle mass, adjusting for confounders such as age, gender, ethnicity, income-to-poverty ratio, and chronic diseases (e.g., diabetes and hypertension). Variance inflation factors (VIF) confirmed the absence of multicollinearity. Lower BMI was significantly associated with higher odds of low muscle mass (adjusted OR: 0.508, 95% CI: 0.483-0.533, p < 0.001), while higher BMI exhibited a protective effect. Age (OR: 1.035, 95% CI: 1.025-1.045, p < 0.001) and female gender (OR: 1.570, 95% CI: 1.267-1.949, p < 0.001) were independent risk factors. Racial disparities were noted, with non-Hispanic Black individuals at lower risk compared to non-Hispanic Whites (OR: 0.242, 95% CI: 0.152-0.384, p < 0.001). Other significant factors included diabetes and alcohol consumption, while education and smoking status were not significantly associated. BMI is inversely associated with low muscle mass prevalence, with lower BMI posing a higher odds. The findings underscore the clinical importance of monitoring BMI and addressing multifactorial risk profiles for low muscle mass management and prevention.

Associations Between Adherence to the Mediterranean Diet and Incident Sarcopenia in Prospective Cohort Studies

The loss of skeletal muscle mass and strength, known as sarcopenia, is prevalent in older adults and linked to an increased risk of disability, frailty, and early mortality. Muscle health is crucial for the functionality and independence of older adults. As the aging population continuously grows, finding cost-effective strategies for preventing and treating sarcopenia is an important public health priority. While nutrition is recognized as a key factor in the development of sarcopenia, its role in preventing and treating the condition is still under investigation. In recent decades, nutritional research has shifted from a focus on individual nutrients or healthy foods to examining the combination of nutrients and foods in dietary patterns, along with their potential synergistic and antagonistic effects. A balanced diet and regular participation in physical activity are essential for maintaining musculoskeletal health. One of the healthy eating patterns with the greatest evidence of multiple health benefits is the Mediterranean diet, which has also been linked to positive effects on muscle function in observational studies. However, there is a lack of intervention studies. This review explores the updated evidence from longitudinal prospective studies on associations between adherence to the Mediterranean diet and sarcopenia in order to promote preventive and intervention strategies for healthy muscle aging.

Role of Nutrition in the Management of Chronic Liver Disease

Malnutrition is prevalent, detrimental, and associated with worse outcomes, including higher rates of hospitalization, morbidity, and mortality. In this review article, we aimed to define malnutrition in patients with chronic liver disease (CLD), elucidate the pathogenesis of malnutrition, discuss the advantages and disadvantages of current screening methods, and highlight the latest evidence-based dietary recommendations. Emerging evidence suggests that CLD-specific tools such as the Liver Disease Undernutrition Screening Tool and the Royal Free Hospital-Nutritional Prioritizing Tool can accurately identify patients at high risk for malnutrition and should be used in conjunction with more standard tools such as subjective global assessments. The pathogenesis of malnutrition in CLD is multifactorial but seems to arise in large from altered metabolism, namely a reduction in protein synthesis and an increase in resting energy expenditure. However, decreased nutrient intake, impaired nutrient absorption and increased nutrient losses have also been shown to contribute. Key findings in this review argue against protein-restricted diets in patients with CLD and support the use of plant-based proteins over dairy and meat proteins for those with liver cirrhosis complicated by hepatic encephalopathy. Frequent small meals are recommended in patients with liver cirrhosis in addition to the avoidance of prolonged fasts >12 hours due to their hypercatabolic state. CLD covers a wide spectrum of diseases, and this review calls for an individualized approach to addressing the specific nutritional needs, depending on the etiology of CLD, its severity, associated complications, and comorbid conditions. This can be best achieved by close, longitudinal follow-up with a multidisciplinary team including a registered dietitian who can obtain a comprehensive, accurate nutritional assessment.

Neurogastroenterology and motility disorders in patients with cirrhosis

Neurogastroenterology and motility disorders are complex gastrointestinal conditions that are prevalent worldwide, particularly affecting women and younger individuals. These conditions significantly impact the quality of life of people suffering from them. There is increasing evidence linking these disorders to cirrhosis, with a higher prevalence compared to the general population. However, the link between neurogastroenterology and motility disorders and cirrhosis remains unclear due to undefined mechanisms. In addition, managing these conditions in cirrhosis is often limited by the adverse effects of drugs commonly used for these disorders, presenting a significant clinical challenge in the routine management of patients with cirrhosis. This review delves into this connection, exploring potential pathophysiological links and clinical interventions between neurogastroenterology disorders and cirrhosis.

Assessing the risk factors associated with nutritional status in patients with liver cirrhosis: A case-control study

BACKGROUND

Cirrhosis is one of the most common clinical diseases in the world. The patient with cirrhosis has many complications, such as spontaneous peritonitis, hepatic encephalopathy. Malnutrition is one of the most common complications in patients with cirrhosis, and it is also a key factor affecting the prognosis of patients. However, the research on cirrhosis malnutrition is relatively scarce.

OBJECTIVE

This study aimed to explore the new factors of the liver cirrhosis with the nutritional status.

METHODS

A total of 370 patients with liver cirrhosis were admitted to the Fourth Affiliated Hospital of Harbin Medical University from January 2019 to January 2023 were selected. Patients were assigned to the malnourished group and normal group. The weight, height, mid arm circumference (MAC) and triceps skinfold thickness (TSF) of the two groups were measured. Body mass index (BMI) and mid-arm muscle circumference (MAMC) were calculated. Furthermore, the Health Literacy Management Scale (HeLMS), biochemical indexes, incidence of complications, disease grade were also counted and the Royal Free Hospital-Nutrition Prioritization Tool were used to evaluate the nutritional status of the patient.

RESULTS

A total of 370 patients was included in this study, including 177 malnutrition patients, accounting for 45.29%, and the scores and total scores of the patients in the malnutrition group were lower than those in the normal group. The measured values of Na+, Alb, PA, T-Bil, TC, TLC, Hb, and RBC were all lower than those of the normal group, and the difference was statistically significant. The overall complication rate of the patients in the malnourished group was 89.61%, and that of the normal group was 39.78%. Multifactorial logistic regression analysis was performed with nutritional level as the dependent variable (normal = 0, malnutrition = 1), and the above indicators of variability (Na+, Alb, PA, T-Bil, TC, PT, Hb, RBC, HG, and HeLMS scores) as the independent variables. The results showed that Na+, Hb were the influencing factors of nutritional level (P< 0.05).

CONCLUSION

The incidence of malnutrition in cirrhotic patients included in this study was at a moderate level, and the nutritional literacy of these patients was low. In addition, the level of serum sodium, Hemoglobin can affect the nutritional level of patients with cirrhosis.

Comparison of the ability between dual-energy X-ray absorptiometry and bioelectrical impedance analysis for diagnosing low skeletal muscle mass and sarcopenia in patients with chronic liver disease

BACKGROUND AND AIM

Sarcopenia and osteoporosis adversely impact the clinical outcomes of patients with chronic liver disease (CLD). The Japan Society of Hepatology (JSH) sarcopenia criteria utilize bioelectrical impedance analysis (BIA) for assessing muscle mass rather than dual-energy X-ray absorptiometry (DXA), which can simultaneously diagnose these comorbidities. We investigated the correlations and interchangeability between the appendicular skeletal muscle mass index (ASMI) values determined using BIA and DXA and evaluated the diagnostic ability of DXA for sarcopenia and osteosarcopenia in patients with CLD.

METHODS

This cross-sectional study included 173 patients with CLD. Sarcopenia was defined as low ASMIBIA according to the JSH and Asian Working Group for Sarcopenia (AWGS) criteria (ASMIBIA cutoff) or low ASMIDXA according to the AWGS criteria (ASMIDXA cutoff) and low handgrip strength. For women, a provisional cutoff value was set for ASMIDXA using the ASMIBIA cutoff (ASMIDXA-altered cutoff).

RESULTS

We found that ASMIBIA and ASMIDXA were significantly correlated (r = 0.921; P < 0.001). The Bland-Altman plots demonstrated substantial agreement between ASMIBIA and ASMIDXA, with a mean difference of 0.0116 kg/m2. The prevalence rates of sarcopenia and osteosarcopenia diagnosed using the ASMIBIA cutoff were 26.0% and 17.3%, respectively. The kappa coefficients for the prevalence of sarcopenia and osteosarcopenia were 0.759 and 0.775 between ASMIBIA cutoff and ASMIDXA cutoff and 0.780 and 0.806 between ASMIBIA cutoff and ASMIDXA-altered cutoff, respectively.

CONCLUSIONS

The utilization of DXA can facilitate the comprehensive assessment and management of musculoskeletal comorbidities in patients with CLD.

Longitudinal Body Composition Identifies Hepatocellular Carcinoma With Cachexia Following Combined Immunotherapy and Target Therapy (CHANCE2213)

BACKGROUND

Cancer cachexia can impact prognosis, cause resistance to anticancer treatments and affect the tolerability of treatments. This study aims to identify hepatocellular carcinoma (HCC) with cachexia by characterizing longitudinal body composition (BC) trajectories.

METHODS

This longitudinal, multicentre cohort study included unresectable HCC patients treated with first-line programmed death-(ligand)1 inhibitors plus anti-vascular endothelial growth factor antibody/tyrosine kinase inhibitors between 01/2018-12/2022. BC measurements including skeletal muscle mass (SMM) and total adipose tissue area (TATA) were evaluated by computed tomography at the third lumbar vertebra at baseline and follow-up imaging. Unsupervised latent class growth mixed models were applied to distinguish potential longitudinal SMM and TATA trajectories for identifying cachexia. The primary study endpoint was overall survival (OS), with secondary endpoints including progression-free survival (PFS), objective response rate (ORR) and safety. Multiple Cox proportional hazards models were used to calculate adjusted hazard ratios (HRs) for survival.

RESULTS

A total of 411 patients with 2138 time-point measurements were included. The median age was 56 years, and 50 (12.2%) patients were female. Two distinct trajectories were identified for SMM and TATA: sharp-falling and stable. SMM sharply declined in 58 patients (14.1%) and TATA in 71 of 406 patients (17.5%) with significant worse OS (for SMM, 17.0 vs. 24.9 months; p < 0.001; HR = 0.59; for TATA, 15.3 vs. 25.1 months; p < 0.001; HR = 0.44). Patients were categorized into three phases based on trajectories: pre-cachexia (SMM and TATA stable, n = 299, 73.6%), cachexia (SMM or TATA sharp-falling, n = 86, 21.2%) and refractory cachexia (SMM and TATA sharp-falling, n = 21, 5.2%). Patients with refractory cachexia exhibited the worst OS, PFS and ORR, followed by those with cachexia. The median OS was 11.5 months for refractory cachexia, 17.7 for cachexia and 26.0 for pre-cachexia; median PFS was 6.0, 7.9 and 10.9 months, respectively, with ORR of 4.8%, 39.5% and 54.2%, respectively (all ps < 0.001). Multivariable Cox analysis identified refractory cachexia as an independent risk factor for both OS (HR = 3.31; p < 0.001) and PFS (HR = 2.94; p < 0.001), with cachexia also showing significant impacts. Grade 3-4 adverse events were higher in patients with refractory cachexia (23.8%) and cachexia (8.1%) compared with pre-cachexia (6.0%; p = 0.010).

CONCLUSIONS

HCC patients with cachexia and refractory cachexia were identified by longitudinal BC trajectories. Falling trajectories of BC identified refractory cachexia patients with worst response, survival and poor tolerability from systemic therapy combinations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT05278195.