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Campos-Varela I, Castells L, Quiroga S, Vargas V, Simon-Talero M. Frailty and sarcopenia in patients with acute-on-chronic liver failure: Assessment and risk in the liver transplant setting. Ann Hepatol 2024:101515. [PMID: 38851394 DOI: 10.1016/j.aohep.2024.101515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/17/2023] [Accepted: 05/31/2024] [Indexed: 06/10/2024]
Abstract
Frailty and sarcopenia are well-recognized factors related to worse outcomes in patients with cirrhosis, including liver transplant (LT) candidates. Implications of pre-LT functional and muscle deterioration also affect post-LT outcomes. Patients with cirrhosis and acute-on-chronic liver failure (ACLF) have a lower survival rate, both before and after LT. There is a need to better identify those patients with ACLF who would benefit from LT. This review aims to present the available data about frailty and sarcopenia in patients with ACLF in the LT setting. An exhaustive review of the published literature was conducted. Data regarding frailty and sarcopenia in LT candidates with ACLF are scarce and heterogeneous. Studies evaluating frailty and sarcopenia in critically ill patients outside the liver literature are also presented in this review to enrich the knowledge of this field in expansion. Frailty and sarcopenia seem to contribute to worse outcomes in LT candidates with ACLF, both before and after LT. Sarcopenia evaluation may be the most prudent approach for those very sick patients. Skeletal muscle index assessed by computed tomography is recommended to evaluate sarcopenia. The role of muscle ultrasound and bioelectrical impedance analysis is to be determined. Frailty and sarcopenia are crucial factors to consider on a case-by-case basis in LT candidates with ACLF to improve patient outcomes best.
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Affiliation(s)
- Isabel Campos-Varela
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
| | - Lluis Castells
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Sergi Quiroga
- Radiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Victor Vargas
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Macarena Simon-Talero
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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2
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Geng D, Wang Y, Wu X, Hu X. Impact of pre-existing frailty on survival outcomes in solid-organ transplant candidates and recipients: A meta-analysis. Ageing Res Rev 2024; 99:102364. [PMID: 38838786 DOI: 10.1016/j.arr.2024.102364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/24/2024] [Accepted: 06/01/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND There is controversy surrounding the association between preexisting frailty and increased mortality in candidates and recipients of solid-organ transplants. This meta-analysis aimed to evaluate the impact of preexisting frailty on survival outcomes in solid-organ transplant candidates and recipients. METHODS A systematic search was conducted in the PubMed, Web of Sciences, and Embase databases until October 2, 2023. Two reviewers independently selected the eligible studies according to the PECOS criteria: Participants (candidates and recipients of solid-organ transplants), Exposure (frailty), Comparison (no-frailty), Outcomes (waitlist or posttransplant mortality), and Study design (retrospective or prospective cohort studies). The pooled effects were summarized by pooling the adjusted hazard ratio (HR) with 95 % confidence intervals (CI) for the frail patients than those without frailty. RESULTS Sixteen studies with 10091 patients met the eligibility criteria. Depending on the frailty tools used, the prevalence of frailty in solid-organ transplant candidates/recipients ranged from 4.6 % to 45.1 %. Frailty was significantly associated with an increased risk of waitlist mortality (HR 2.44; 95 % CI 1.84-3.24) and posttransplant mortality (HR 2.23; 95 % CI 1.61-3.09) in solid-organ transplant candidates and recipients, respectively. Subgroup analyses showed that the association of preexisting frailty with waitlist mortality and posttransplant mortality appeared to stronger in kidney transplant candidates (HR 2.70; 95 % CI 1.93-3.78) and lung transplantation recipients (HR 2.52; 95 % CI 1.23-5.15). CONCLUSION Frailty is a significant predictor of reduced survival in solid-organ transplant candidates and recipients. Assessment of frailty has the potential to identify patients who are suitable for transplantation.
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Affiliation(s)
- Donghua Geng
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Yuxin Wang
- Department of Vascular and Thyroid Surgery, The First Affiliated Hospital, China Medical University, Shenyang 110001, China
| | - Xinyue Wu
- Department of Vascular and Thyroid Surgery, The First Affiliated Hospital, China Medical University, Shenyang 110001, China
| | - Xinhua Hu
- Department of Vascular and Thyroid Surgery, The First Affiliated Hospital, China Medical University, Shenyang 110001, China.
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Schleicher EM, Kaps L, Schattenberg JM, Galle PR, Wörns MA, Gairing SJ, Labenz C. Higher scores in the Clinical Frailty Scale are associated with covert and overt hepatic encephalopathy in patients with cirrhosis. Dig Liver Dis 2024; 56:1046-1053. [PMID: 38105147 DOI: 10.1016/j.dld.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/15/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Frailty increases the vulnerability to internal and external stressors and may therefore be an indicator of a higher frequency of cirrhosis complications. We aimed to investigate the association of the Clinical Frailty Scale (CFS) with covert (CHE) and overt HE (OHE) development in patients with cirrhosis. METHODS This study analyzed data of 228 patients with cirrhosis. Frailty was assessed using CFS. Patients were examined for the presence of CHE (using PHES) at study inclusion and followed for OHE. RESULTS Median CFS was 3 and 26 (11 %) patients were at least pre-frail (CFS>3). In multivariable logistic regression analysis in patients without a history of OHE (n = 195), a higher CFS was associated with the presence of CHE at baseline (OR 1.6, p = 0.039). During follow-up, 42 (18 %) patients developed an episode of OHE. In multivariable competing risk regression analyses, a higher CFS was independently associated with the development of an OHE episode in the total cohort (sHR 1.97, p < 0.001) and in the subcohort of patients without a history of OHE (sHR 1.88, p = 0.008). CONCLUSION CFS appears to be a reliable tool to identify patients at higher risk of HE in whom intensified monitoring and treatment may be justified.
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Affiliation(s)
- Eva Maria Schleicher
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Leonard Kaps
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Jörn M Schattenberg
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Peter Robert Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Marcus-Alexander Wörns
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Department of Gastroenterology, Hematology, Oncology and Endocrinology, Klinikum Dortmund, Germany
| | - Simon Johannes Gairing
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.
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Yuan C, Li W, Liu J, Li J. Frailty and transplant-free survival of patients with liver cirrhosis: A meta-analysis. PLoS One 2024; 19:e0302836. [PMID: 38722913 PMCID: PMC11081249 DOI: 10.1371/journal.pone.0302836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/12/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Frailty is a common condition among patients with liver cirrhosis. Nonetheless, its role in predicting liver transplant-free survival (TFS) remains unclear. AIM This systematic review and meta-analysis were conducted to elucidate the relationship between frailty and TFS in patients with cirrhosis. METHODS Cohort studies addressing the objective of this meta-analysis were extracted from PubMed, Embase, and Web of Science databases. Between-study heterogeneity was assessed with the Cochrane Q test, and the I^2 statistic was estimated. Random-effect models, considering potential heterogeneity, were employed to combine the results. RESULTS The meta-analysis encompassed 17 cohort studies involving 6273 patients with cirrhosis, of whom 1983 (31.6%) were classified as frail at baseline. The follow-up periods in the included studies ranged from 3 to 29 months, with an average duration of 11.5 months. The analysis revealed that frailty was significantly associated with a poor TFS (risk ratio [RR]: 2.07, 95% confidence interval: 1.72 to 2.50, p<0.001; I2 = 51%). Sensitivity analyses that sequentially omitted one dataset consistently supported these findings (RR: 1.95 to 2.17, p<0.05 in all cases). Subgroup analyses based on variables such as study design, mean age of patients, baseline Model for End-Stage Liver Disease score, tool used for frailty evaluation, follow-up duration, and study quality score also yielded congruent results. CONCLUSIONS The evidence suggests that frailty may be an independent risk factor for poor TFS in patients with liver cirrhosis, thus emphasizing the importance of early identification and management of frailty in this population.
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Affiliation(s)
- Chunhui Yuan
- Department of Gastroenterology, Changsha Fourth Hospital, Changsha, Hunan Province, China
| | - Weihua Li
- Department of Gastroenterology, Changsha Fourth Hospital, Changsha, Hunan Province, China
| | - Jie Liu
- Department of Gastroenterology, Changsha Fourth Hospital, Changsha, Hunan Province, China
| | - Jianguo Li
- Department of Gastroenterology, Changsha Fourth Hospital, Changsha, Hunan Province, China
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Asscher VER, Rodriguez Gírondo M, Fens J, Waars SN, Stuyt RJL, Baven-Pronk AMC, Srivastava N, Jacobs RJ, Haans JJL, Meijer LJ, Klijnsma-Slagboom JD, Duin MH, Peters MER, Lee-Kong FVYL, Provoost NE, Tijdeman F, van Dijk KT, Wieland MWM, Verstegen MGM, van der Meijs ME, Maan ADI, van Deudekom FJ, van der Meulen-de Jong AE, Mooijaart SP, Maljaars PWJ. Frailty Screening is Associated with Hospitalization and Decline in Quality of Life and Functional Status in Older Patients with Inflammatory Bowel Disease. J Crohns Colitis 2024; 18:516-524. [PMID: 37870484 PMCID: PMC11037105 DOI: 10.1093/ecco-jcc/jjad175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND AND AIMS Our goals were to study frailty screening in association with hospitalization and decline in quality of life [QoL] and functional status in older patients with inflammatory bowel diseases [IBD]. METHODS This was a prospective multicentre cohort study in IBD patients ≥65 years old using frailty screening [G8 Questionnaire]. Outcomes were all-cause, acute, and IBD-related hospitalization, any infection, any malignancy, QoL [EQ5D-3L], and functional decline (Instrumental Activities of Daily Living [IADL]) during 18 months of follow-up. Confounders were age, IBD type, biochemical disease activity [C-reactive protein ≥10 mg/L and/or faecal calprotectin ≥250 µg/g], and comorbidity [Charlson Comorbidity Index]. RESULTS Of 405 patients, with a median age of 70 years, 196 [48%] were screened as being at risk for frailty. All-cause hospitalizations occurred 136 times in 96 patients [23.7%], and acute hospitalizations 103 times in 74 patients [18.3%]. Risk of frailty was not associated with all-cause (adjusted hazard ratio [aHR] 1.5, 95% confidence interval [CI] 0.9-2.4), but was associated with acute hospitalizations [aHR 2.2, 95% CI 1.3-3.8]. Infections occurred in 86 patients [21.2%] and these were not associated with frailty. A decline in QoL was experienced by 108 [30.6%] patients, and a decline in functional status by 46 patients [13.3%]. Frailty screening was associated with a decline in QoL (adjusted odds ratio [aOR] 2.1, 95% CI 1.3-3.6) and functional status [aOR 3.7, 95% CI 1.7-8.1]. CONCLUSIONS Frailty screening is associated with worse health outcomes in older patients with IBD. Further studies are needed to assess the feasibility and effectiveness of its implementation in routine care.
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Affiliation(s)
- Vera E R Asscher
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mar Rodriguez Gírondo
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Jesse Fens
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Sanne N Waars
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Rogier J L Stuyt
- Department of Gastroenterology and Hepatology, HagaZiekenhuis, The Hague, the Netherlands
| | - A Martine C Baven-Pronk
- Department of Gastroenterology and Hepatology, Groene Hart Ziekenhuis, Gouda, the Netherlands
| | - Nidhi Srivastava
- Department of Gastroenterology and Hepatology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - Rutger J Jacobs
- Department of Gastroenterology and Hepatology, Alrijne Hospital, Leiden and Leiderdorp, the Netherlands
| | - Jeoffrey J L Haans
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Lennart J Meijer
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Marijn H Duin
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Milou E R Peters
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Felicia V Y L Lee-Kong
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Nanda E Provoost
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Femke Tijdeman
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Kenan T van Dijk
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Monse W M Wieland
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mirre G M Verstegen
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Melissa E van der Meijs
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Annemijn D I Maan
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Floor J van Deudekom
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - P W Jeroen Maljaars
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
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Mendez-Guerrero O, Carranza-Carrasco A, Chi-Cervera LA, Torre A, Navarro-Alvarez N. Optimizing nutrition in hepatic cirrhosis: A comprehensive assessment and care approach. World J Gastroenterol 2024; 30:1313-1328. [PMID: 38596498 PMCID: PMC11000076 DOI: 10.3748/wjg.v30.i10.1313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/23/2024] [Accepted: 02/25/2024] [Indexed: 03/14/2024] Open
Abstract
Cirrhosis is considered a growing cause of morbidity and mortality, which represents a significant public health problem. Currently, there is no effective treatment to reverse cirrhosis. Treatment primarily centers on addressing the underlying liver condition, monitoring, and managing portal hypertension-related complications, and evaluating the potential for liver transplantation in cases of decompensated cirrhosis, marked by rapid progression and the emergence of complications like variceal bleeding, hepatic encephalopathy, ascites, malnutrition, and more. Malnutrition, a prevalent complication across all disease stages, is often underdiagnosed in cirrhosis due to the complexities of nutritional assessment in patients with fluid retention and/or obesity, despite its crucial impact on prognosis. Increasing emphasis has been placed on the collaboration of nutritionists within hepatology and Liver transplant teams to deliver comprehensive care, a practice that has shown to improve outcomes. This review covers appropriate screening and assessment methods for evaluating the nutritional status of this population, diagnostic approaches for malnutrition, and context-specific nutrition treatments. It also discusses evidence-based recommendations for supplementation and physical exercise, both essential elements of the standard care provided to cirrhotic patients.
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Affiliation(s)
- Osvely Mendez-Guerrero
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Anaisa Carranza-Carrasco
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Luis Alberto Chi-Cervera
- Clínica de Especialidades Gastrointestinales y Hepáticas, Hospital Star Medica, Merida 97133, Yucatan, Mexico
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Nalu Navarro-Alvarez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Molecular Biology, Universidad Panamericana School of Medicine, Campus México, Mexico City 03920, Mexico
- Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO 80045, United States
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Ismond KP, Cruz C, Limon-Miro AT, Low G, Prado CM, Spence JC, Raman M, McNeely ML, Tandon P. An open label feasibility study of a nutrition and exercise app-based solution in cirrhosis. CANADIAN LIVER JOURNAL 2024; 7:5-15. [PMID: 38505789 PMCID: PMC10946184 DOI: 10.3138/canlivj-2023-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/10/2023] [Indexed: 03/21/2024]
Abstract
Background Nutrition and exercise are the mainstay of therapy for the prevention and treatment of frailty in cirrhosis. This pilot study assessed feasibility of the online delivery of an app-based semi-supervised nutrition and exercise intervention in this population. Methods The 11-week pilot recruited adults with cirrhosis who owned internet-connected devices. Patients were encouraged to participate in exercise sessions 3× per week including a combination of online group exercise (weekly) and home-based follow-along exercise (biweekly). They also participated in group nutrition classes (five sessions) and one-to-one exercise and nutrition check-ins delivered through the app. Primary outcome measures pertained to program feasibility: recruitment, retention, adherence, and satisfaction. Exploratory measures included physical performance (liver frailty index [LFI], 6-minute walk test [6MWT]), health behaviour domains, and quality of life. Results Twenty three patients completed baseline measures. Of these, 18 (72%) completed end of study measures (mean MELD-Na, 9.2; female, 44.4%). Over 70% of participants fulfilled 75% or more of the feasibility criteria. Satisfaction with the program was high (mean, 89%). Exercise program modifications were required for 17 patients to accommodate health events or abilities. Exploratory evaluation showed improvement in the LFI and the 6MWT by -0.58-units (95% CI: -0.91 to -0.25) and 46.0 m (95% CI: 22.7-69.3) respectively without changes in quality of life or health behaviour domains. Conclusions Outcomes demonstrate feasibility of the app-based delivery of programming with promising exploratory impact on efficacy for physical performance. Findings can guide the design of a large-scale app-based randomized controlled trials in cirrhosis.
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Affiliation(s)
- Kathleen P Ismond
- Division of Gastroenterology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Christofer Cruz
- Division of Gastroenterology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ana Teresa Limon-Miro
- Division of Gastroenterology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Gavin Low
- Division of Gastroenterology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Carla M Prado
- Department of Agricultural, Food and Nutritional Science, Faculty of Agricultural, Life and Environmental Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - John C Spence
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Maitreyi Raman
- Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Margaret L McNeely
- Department of Physical Therapy/ Department of Oncology, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Puneeta Tandon
- Division of Gastroenterology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Thuluvath AJ, Duarte-Rojo A, Lai JC, Peipert J, Dietch ZC, Siddiqui O, Morrissey S, Belfanti K, Zhao L, Guo K, Nizamuddin M, Polineni P, Levitsky J, Flores AM, Ladner DP. Brief PROMIS Assessment Screens for Frailty and Predicts Hospitalizations in Liver Transplant Candidates. Transplantation 2024; 108:491-497. [PMID: 37496147 DOI: 10.1097/tp.0000000000004741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND Frailty is prevalent in patients with end-stage liver disease and predicts waitlist mortality, posttransplant mortality, and frequency of hospitalizations. The Liver Frailty Index (LFI) is a validated measure of frailty in liver transplant (LT) candidates but requires an in-person assessment. METHODS We studied the association between patient-reported physical function and LFI in a single-center prospective study of adult patients with cirrhosis undergoing LT evaluation from October 2020 to December 2021. Frailty was assessed with the LFI and 4-m gait speed. Patient-reported physical function was evaluated using a brief Patient-Reported Outcomes Measurement Information System (PROMIS) survey. RESULTS Eighty-one LT candidates were enrolled, with a mean model of end-stage liver disease-sodium of 17.6 (±6.3). The mean LFI was 3.7 (±0.77; 15% frail and 59% prefrail) and the mean PROMIS Physical Function score was 45 (±8.6). PROMIS Physical Function correlated with LFI ( r = -0.54, P < 0.001) and 4-m gait speed ( r = 0.48, P < 0.001). The mean hospitalization rate was 1.1 d admitted per month. After adjusting for age, sex, and model of end-stage liver disease-sodium, patient-reported physical function-predicted hospitalization rate ( P = 0.001). CONCLUSIONS This study suggests that a brief patient-reported outcome measure can be used to screen for frailty and predict hospitalizations in patients with cirrhosis.
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Affiliation(s)
- Avesh J Thuluvath
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Starzl Transplantation Institute, and Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - John Peipert
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Zachary C Dietch
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Transplant, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Osama Siddiqui
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Sheila Morrissey
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Kimberly Belfanti
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Lihui Zhao
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern Medicine, Chicago, IL
| | - Kexin Guo
- Department of Preventive Medicine, Biostatistics Collaboration Center, Northwestern Medicine, Chicago, IL
| | - Mohammad Nizamuddin
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Praneet Polineni
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Josh Levitsky
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Ann-Marie Flores
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Cancer Survivorship Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
| | - Daniela P Ladner
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Division of Transplant, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Ilyas F, Aloor FZ, Satapathy SK. Sarcopenia and Frailty in Advanced Liver Disease Patients: A Comprehensive Review. CURRENT HEPATOLOGY REPORTS 2024; 23:88-98. [DOI: 10.1007/s11901-024-00640-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 04/26/2024]
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Santangeli E, Abbati C, Chen R, Di Carlo A, Leoni S, Piscaglia F, Ferri S. Pathophysiological-Based Nutritional Interventions in Cirrhotic Patients with Sarcopenic Obesity: A State-of-the-Art Narrative Review. Nutrients 2024; 16:427. [PMID: 38337711 PMCID: PMC10857546 DOI: 10.3390/nu16030427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
In recent decades, following the spread of obesity, metabolic dysfunction has come to represent the leading cause of liver disease. The classical clinical presentation of the cirrhotic patient has, therefore, greatly changed, with a dramatic increase in subjects who appear overweight or obese. Due to an obesogenic lifestyle (lack of physical activity and overall malnutrition, with an excess of caloric intake together with a deficit of proteins and micronutrients), these patients frequently develop a complex clinical condition defined as sarcopenic obesity (SO). The interplay between cirrhosis and SO lies in the sharing of multiple pathogenetic mechanisms, including malnutrition/malabsorption, chronic inflammation, hyperammonemia and insulin resistance. The presence of SO worsens the outcome of cirrhotic patients, affecting overall morbidity and mortality. International nutrition and liver diseases societies strongly agree on recommending the use of food as an integral part of the healing process in the comprehensive management of these patients, including a reduction in caloric intake, protein and micronutrient supplementation and sodium restriction. Based on the pathophysiological paths shared by cirrhosis and SO, this narrative review aims to highlight the nutritional interventions currently advocated by international guidelines, as well as to provide hints on the possible role of micronutrients and nutraceuticals in the treatment of this multifaceted clinical condition.
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Affiliation(s)
- Ernestina Santangeli
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (E.S.); (C.A.); (R.C.); (F.P.)
| | - Chiara Abbati
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (E.S.); (C.A.); (R.C.); (F.P.)
| | - Rusi Chen
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (E.S.); (C.A.); (R.C.); (F.P.)
| | - Alma Di Carlo
- Division of Internal Medicine, Hepatobiliary and Immunoallergologic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.D.C.); (S.L.)
| | - Simona Leoni
- Division of Internal Medicine, Hepatobiliary and Immunoallergologic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.D.C.); (S.L.)
| | - Fabio Piscaglia
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (E.S.); (C.A.); (R.C.); (F.P.)
- Division of Internal Medicine, Hepatobiliary and Immunoallergologic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.D.C.); (S.L.)
| | - Silvia Ferri
- Division of Internal Medicine, Hepatobiliary and Immunoallergologic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.D.C.); (S.L.)
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Wang M, Shui AM, Ruck J, King E, Rahimi R, Kappus M, Volk ML, Ganger DR, Ladner DP, Duarte-Rojo A, Huang CY, Verna EC, Lai JC. The liver frailty index is a predictor of healthcare utilization after liver transplantation in older adults. Clin Transplant 2024; 38:e15219. [PMID: 38064281 PMCID: PMC11042074 DOI: 10.1111/ctr.15219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 11/15/2023] [Accepted: 11/26/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND Older adults have higher healthcare utilization after liver transplantation (LT), yet objective risk stratification tools in this population are lacking. We evaluated the Liver Frailty Index (LFI) as one potential tool. METHODS Ambulatory LT candidates ≥65 years without hepatocellular carcinoma (HCC) who underwent LT from 1/2012 to 6/2022 at 8 U.S. centers were included. Estimates of the difference in median using quantile regression were used to assess the adjusted association between LFI and hospitalized days within 90 days post-LT. RESULTS Of 131 LT recipients, median (interquartile range [IQR]) (1st -3rd quartiles) age was 68 years (66-70); median pre-LT MELD-Na was 19 (15-24). Median LFI was 4.1 (3.6-4.7); 27% were frail (LFI≥4.5). Median hospitalized days within 90 days post-LT was 11 (7-20). Compared with non-frail patients, frail patients were hospitalized for a median of 5 days longer post-LT (95% CI .30-9.7, p = .04). Each .5 unit increase in pre-LT LFI was associated with an increase of 1.16 days (95%CI .42-2.69, p = .02) in hospitalized days post-LT. CONCLUSION Among older adults undergoing LT, frailty was associated with more hospitalized days within 90 days after LT. The LFI can identify older adults who might benefit from pre-LT or early post-LT programs which may reduce post-LT healthcare utilization, such as early rehabilitation or post-hospital discharge programs.
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Affiliation(s)
- Melinda Wang
- Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Amy M. Shui
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Jessica Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert Rahimi
- Division of Gastroenterology and Hepatology, Department of Medicine, Baylor Scott and White Health, Dallas, Texas, USA
| | - Matthew Kappus
- Division of Gastroenterology, Department of Medicine, Duke University Hospital, Durham, North Carolina, USA
| | - Michael L. Volk
- Division of Gastroenterology and Nutrition, Department of Medicine, Loma Linda University, Loma Linda, California, USA
| | - Daniel R. Ganger
- Division of Gastroenterology and Nutrition, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniela P. Ladner
- Division of Organ Transplantation, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Elizabeth C. Verna
- Center for Liver Division of Digestive and Liver Diseases, Diseases and Transplantation, Columbia University Medical Center, New York, New York, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
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12
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Duarte-Rojo A, Bux R, Sliwa J. Untangling frailty, sarcopenia, and physical fitness in cirrhosis. Clin Liver Dis (Hoboken) 2024; 23:e0213. [PMID: 38841195 PMCID: PMC11152786 DOI: 10.1097/cld.0000000000000213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/01/2024] [Indexed: 06/07/2024] Open
Affiliation(s)
- Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Northwestern Feinberg School of Medicine; Chicago, Illinois, USA
- Comprehensive Transplant Center, Northwestern Medicine, Chicago, Illinois, USA
| | - Rehaan Bux
- Comprehensive Transplant Center, Northwestern Medicine, Chicago, Illinois, USA
| | - James Sliwa
- Shirley Ryan Ability Lab, Department of Physical Medicine & Rehabilitation, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
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13
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Elsheikh M, El Sabagh A, Mohamed IB, Bhongade M, Hassan MM, Jalal PK. Frailty in end-stage liver disease: Understanding pathophysiology, tools for assessment, and strategies for management. World J Gastroenterol 2023; 29:6028-6048. [PMID: 38130738 PMCID: PMC10731159 DOI: 10.3748/wjg.v29.i46.6028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/08/2023] [Accepted: 12/01/2023] [Indexed: 12/13/2023] Open
Abstract
Frailty and sarcopenia are frequently observed in patients with end-stage liver disease. Frailty is a complex condition that arises from deteriorations across various physiological systems, including the musculoskeletal, cardiovascular, and immune systems, resulting in a reduced ability of the body to withstand stressors. This condition is associated with declined resilience and increased vulnerability to negative outcomes, including disability, hospitalization, and mortality. In cirrhotic patients, frailty is influenced by multiple factors, such as hyperammonemia, hormonal imbalance, malnutrition, ascites, hepatic encephalopathy, and alcohol intake. Assessing frailty is crucial in predicting morbidity and mortality in cirrhotic patients. It can aid in making critical decisions regarding patients' eligibility for critical care and transplantation. This, in turn, can guide the development of an individualized treatment plan for each patient with cirrhosis, with a focus on prioritizing exercise, proper nutrition, and appropriate treatment of hepatic complications as the primary lines of treatment. In this review, we aim to explore the topic of frailty in liver diseases, with a particular emphasis on pathophysiology, clinical assessment, and discuss strategies for preventing frailty through effective treatment of hepatic complications. Furthermore, we explore novel assessment and management strategies that have emerged in recent years, including the use of wearable technology and telemedicine.
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Affiliation(s)
- Mazen Elsheikh
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Ahmed El Sabagh
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Islam B Mohamed
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Megha Bhongade
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Manal M Hassan
- Department of Epidemiology, Division of Cancer Prevention and Population Sciences, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Prasun Kumar Jalal
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX 77030, United States
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Musto JA, Lucey MR. Prognostic models in alcohol-related liver disease and alcohol-related hepatitis. Best Pract Res Clin Gastroenterol 2023; 67:101867. [PMID: 38103931 DOI: 10.1016/j.bpg.2023.101867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 08/18/2023] [Indexed: 12/19/2023]
Abstract
Alcohol-associated liver disease (ALD) and alcohol-associated hepatitis (AH) are dynamic disorders whose prognosis can be challenging to determine. A number of prognostic models have been developed to determine likelihood of death, when to refer for liver transplant (LT) and the role for glucocorticoids. Often these models were created with a specific application in mind but were found to have additional applications with further study. Those prognostic models that have stood the test of time are easy to use, have clear interpretations and employ objective parameters. These parameters most often include total bilirubin, INR and creatinine among other data points. Ideally, these models could be utilized at all phases of disease but in most, it is important for clinicians to consider drinking history and how it might alter the determined scores. Herein we provide a brief review of prognostic models in ALD and AH and provide practical tips and considerations to successfully make use of these tools in a clinical setting.
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Affiliation(s)
- Jessica Ann Musto
- Department of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Michael Ronan Lucey
- Department of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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15
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Zhang H, Wei X, Chen X, Sun X. Mortality from all-cause and cause-specific in the elderly: Joint implications of anemia and frailty. Arch Gerontol Geriatr 2023; 115:105213. [PMID: 37783022 DOI: 10.1016/j.archger.2023.105213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/30/2023] [Accepted: 09/23/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Anemia is prevalent among older adults, and it contributes to the incidence of frailty. In turn, the frail elderly may be deficient in nutrients, including iron, vitamin B-12, and folate, that can be materials for human blood, as a result of their limited nutrient intake, resulting in anemia. Both anemia and frailty are associated with an increased risk of mortality in elderly adults. However, the combined influence of anemia and frailty on mortality is unclear. METHODS Data obtained from NHANES 2007-2014 were analyzed in this study. Frailty status was determined using a modified Fried Phenotype, and anemia was defined according to the criteria set by the World Health Organization. Public-use Linked Mortality files until December 31, 2019 were available. The weighted Cox proportional hazard regression models were used to estimate separate effects and joint effects of frailty and anemia on all-cause and cause-specific mortality. RESULTS This study analyzed 6,406 participants aged 60 years or older. Over a 13-year follow-up period, considering participants with no anemia and no frailty as reference, participants with both anemia and frailty had nearly fourfold the all-cause (HR (95% CI): 4.03 (2.95,5.52)), more than four-time the cardiovascular (HR (95% CI): 4.24(2.46,7.32)) mortality risk, and above five-time the non-CVD/non-cancer (HR (95% CI): 5.17 (3.58,7.46)) mortality risk. CONCLUSIONS The study indicated that older adults who exhibit low levels of hemoglobin and frailty are at the greatest risk for all-cause, cardiovascular, cancer, and non-cancer/non-cardiovascular mortality, with the exception of cancer mortality, which was only increased by anemia.
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Affiliation(s)
- HuanRui Zhang
- Department of Geriatric, The First Hospital of China Medical University, NO.155 Nanjing North Street, Heping Ward, Shenyang 110001, China
| | - Xuejiao Wei
- Department of health services and policy research, Queen's University, Kingston, ON, Canada
| | - XiTao Chen
- Department of Thoracic Surgery, The First Hospital of China Medical University, NO.155 Nanjing North Street, Heping Ward, Shenyang 110001, China.
| | - XiaoDi Sun
- Department of Geriatric, The First Hospital of China Medical University, NO.155 Nanjing North Street, Heping Ward, Shenyang 110001, China.
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Duarte-Rojo A, Bloomer PM, Grubbs RK, Stine JG, Ladner D, Hughes CB, Dunn MA, Jakicic JM. Use of a Mobile-Assisted Telehealth Regimen to Increase Exercise in Transplant Candidates: A Home-Based Prehabilitation Pilot and Feasibility Trial. Clin Transl Gastroenterol 2023; 14:e00601. [PMID: 37477616 PMCID: PMC10684184 DOI: 10.14309/ctg.0000000000000601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/01/2023] [Indexed: 07/22/2023] Open
Abstract
INTRODUCTION Physical fitness assessed by the Liver Frailty Index (LFI) and 6-minute walk test (6MWT) informs the prognosis of liver transplant candidates, although there are limited data on its reversibility after prehabilitation. On a home-based exercise trial, we aimed to improve LFI and 6MWT and to investigate trial feasibility and intervention adherence. METHODS Liver transplant candidates with cirrhosis wore a personal activity tracker and used Exercise and Liver FITness app for 14 weeks, including a 2-week technology acclimation run-in. The 12-week intervention consisted of Exercise and Liver FITness app plus personal activity tracker and 15-/30-minute weekly calls with a physical activity coach aiming to complete ≥2 video-training sessions/week, or ≥500 step/d baseline increase for ≥8 weeks. We defined feasibility as ≥66% of subjects engaging in the intervention phase and adherence as ≥50% subjects meeting training end point. RESULTS Thirty-one patients (61 ± 7 years, 71% female, model for end-stage liver disease 17 ± 5, ∼33% frail) consented and 21 (68%) started the intervention. In the 15 subjects who completed the study, LFI improved from 3.84 ± 0.71 to 3.47 ± 0.90 ( P = 0.03) and 6MWT from 318 ± 73 to 358 ± 64 m ( P = 0.005). Attrition reasons included death (n = 4) and surgery (n = 2). There was 57% adherence, better for videos than for walking, although daily steps significantly increased (3,508 vs baseline: 1,260) during best performance week. One adverse event was attributed to the intervention. DISCUSSION Our clinical trial meaningfully improved LFI by 0.4 and 6MWT by 41 m and met feasibility/adherence goals. In-training daily step increase supported physical self-efficacy and intervention uptake, but maintenance remained a challenge despite counseling.
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Affiliation(s)
- Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
- Comprehensive Transplant Center, Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois, USA
- Division Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pamela M. Bloomer
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rachel K. Grubbs
- Division Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jonathan G. Stine
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Daniela Ladner
- Comprehensive Transplant Center, Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Christopher B. Hughes
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael A. Dunn
- Division Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John M. Jakicic
- Division of Physical Activity and Weight Management, University of Kansas, Kansas, KA, USA
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17
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Loschi TM, Baccan MDTA, Della Guardia B, Martins PN, Boteon APCS, Boteon YL. Exercise training as an intervention for frailty in cirrhotic patients on the liver transplant waiting list: A systematic review. World J Hepatol 2023; 15:1153-1163. [PMID: 37970618 PMCID: PMC10642435 DOI: 10.4254/wjh.v15.i10.1153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/21/2023] [Accepted: 10/08/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND The existing literature suggests that exercise for cirrhotic patients is safe and favours significant improvement to their physical capacity. However, exercise training for this population and how to deliver activities, especially in severe stages of the disease and while waiting for a liver transplant (LT), remain undefined. AIM To review the existing exercise prescriptions for cirrhotic patients on the waiting list for LT, their results for frailty evolution and their effect on clinical outcomes. METHODS A systematic review was performed following the Preferred Reporting Review and Meta-Analysis guidelines and searching the PubMed, MEDLINE, and Scopus databases. The keyword "liver transplant" was used in combination with the free terms "frailty" and "exercise" for the literature review. Clinical studies that evaluated the effect of a regular training program, independent of supervision or the duration or intensity of physical exercise, in cirrhotic patients on the waiting list for LT were reviewed. The data on safe physical activity prescriptions following Frequency, Intensity, Time, and Type recommendations were extracted and summarised. RESULTS Nine articles met the inclusion criteria for this review. Various instruments for frailty assessment were used, frequently in combination. Five studies prescribed physical activity for patients, one in-person and four to be performed remotely and unsupervised. The remaining four studies only used a self-report instrument to assess the level of physical activity. None reported adverse events related to exercise training. The exercise frequency mainly varied from daily to a minimum of twice per week. The intensity depended on frailty and included increasing levels of activity. The type of exercise was predominantly a combination of aerobic and resistance training. The duration of exercise varied from 4 to 12 wk. Three articles evaluated the effect of the exercise program on clinical outcomes, reporting a reduction in 90-d readmission rates post-transplant and improved frailty scores, as well as improved survival of cirrhotic patients waiting for LT. CONCLUSION Routine frailty assessment is essential for this population. Although more robust evidence is required, the prescription of exercise is safe and can improve patients' functional capacity, improving pre- and post-LT outcomes.
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Affiliation(s)
- Thais Mellato Loschi
- Transplant Centre, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo 05652-900, Brazil
| | - Melline D T A Baccan
- Transplant Centre, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Bianca Della Guardia
- Transplant Centre, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Paulo N Martins
- Department of Surgery, Transplant Division, University of Massachusetts Medical School, Worcester, MA 01655, United States
| | - Amanda P C S Boteon
- Transplant Centre, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Yuri L Boteon
- Transplant Centre, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo 05652-900, Brazil.
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Colosimo S, Bertoli S, Saffioti F. Use of Branched-Chain Amino Acids as a Potential Treatment for Improving Nutrition-Related Outcomes in Advanced Chronic Liver Disease. Nutrients 2023; 15:4190. [PMID: 37836474 PMCID: PMC10574343 DOI: 10.3390/nu15194190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Advanced chronic liver disease (ACLD) represents a complex and multifactorial clinical entity characterized by liver dysfunction and associated complications. In recent years, the significance of nutritional status in ACLD prognosis has gained considerable attention. This review article delves into the multifactorial pathogenesis of malnutrition in ACLD and its profound consequences for health outcomes. We explore the clinical implications of secondary sarcopenia in ACLD and highlight the critical relevance of frailty in both decompensated and compensated ACLD. A specific focus of this review revolves around branched-chain amino acids (BCAAs) and their pivotal role in managing liver disease. We dissect the intricate relationship between low Fischer's ratio and BCAA metabolism in ACLD, shedding light on the molecular mechanisms involved. Furthermore, we critically evaluate the existing evidence regarding the effects of BCAA supplementation on outcomes in ACLD patients, examining their potential to ameliorate the nutritional deficiencies and associated complications in this population.
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Affiliation(s)
- Santo Colosimo
- School of Nutrition Science, University of Milan, 20133 Milan, Italy
- Department of Food, Environmental and Nutritional Sciences (DeFENS), University of Milan, 20133 Milan, Italy
| | - Simona Bertoli
- Department of Food, Environmental and Nutritional Sciences (DeFENS), University of Milan, 20133 Milan, Italy
- Laboratory of Clinical Studies on Obesity, Istituto Auxologico Italiano IRCCS, 20145 Milan, Italy
| | - Francesca Saffioti
- Oxford Liver Unit, Department of Gastroenterology and Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK;
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19
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Choi WM. Pretransplant Frailty on Postoperative Morbidity and Mortality after Liver Transplantation: Bystander or Upstander? Gut Liver 2023; 17:670-671. [PMID: 37712189 PMCID: PMC10502495 DOI: 10.5009/gnl230316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Affiliation(s)
- Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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20
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Goh MJ, Kim J, Chang WH, Sinn DH, Gwak GY, Paik YH, Choi MS, Lee JH, Koh KC, Paik SW, Kim JM, Kang W. Pretransplant Functional Status Predicts Postoperative Morbidity and Mortality after Liver Transplantation in Patients with Cirrhosis. Gut Liver 2023; 17:786-794. [PMID: 36789574 PMCID: PMC10502487 DOI: 10.5009/gnl220337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 10/11/2022] [Accepted: 11/01/2022] [Indexed: 02/16/2023] Open
Abstract
Background/Aims This study aimed to investigate whether pretransplant frailty can predict postoperative morbidity and mortality after liver transplantation (LT) in patients with cirrhosis. Methods We retrospectively reviewed 242 patients who underwent LT between 2018 and 2020 at a tertiary hospital in Korea. Results Among them, 189 patients (78.1%) received LT from a living donor. Physical frailty at baseline was assessed by the Short Physical Performance Battery (SPPB), by which patients were categorized into two groups: frail (SPPB <10) and non-frail (SPPB ≥10). Among the whole cohort (age, 55.0±9.2 years; male, 165 [68.2%]), 182 patients were classified as non-frail and 60 patients were classified as frail. Posttransplant survival was shorter in the frail group than the non-frail group (9.3 months vs 11.6 months). Postoperative intensive care unit stay was longer in the frail group than in the non-frail group (median, 6 days vs 4 days), and the 30-day complication rate was higher in the frail group than in the non-frail group (78.3% vs 59.3%). Frailty was an independent risk factor for posttransplant mortality (adjusted hazard ratio, 2.38; 95% confidence interval, 1.02 to 5.57). In subgroup analysis, frail patients showed lower posttransplant survival regardless of history of hepatocellular carcinoma and donor type. Conclusions Assessment of pretransplant frailty, as measured by SPPB, provides important prognostic information for clinical outcomes in cirrhotic patients undergoing LT.
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Affiliation(s)
- Myung Ji Goh
- Departments of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jihye Kim
- Departments of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Hyuk Chang
- Departments of Physical and Rehabilitation Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Hyun Sinn
- Departments of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Geum-Yeon Gwak
- Departments of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong-Han Paik
- Departments of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Seok Choi
- Departments of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Hyeok Lee
- Departments of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Cheol Koh
- Departments of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Woon Paik
- Departments of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Man Kim
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wonseok Kang
- Departments of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, Korea
- Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
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Arisar FAQ, Chen S, Chen C, Shaikh N, Karnam RS, Xu W, Asrani SK, Galvin Z, Hirschfield G, Patel K, Tsien C, Selzner N, Cattral M, Lilly L, Bhat M. Availability of living donor optimizes timing of liver transplant in high-risk waitlisted cirrhosis patients. Aging (Albany NY) 2023; 15:8594-8612. [PMID: 37665673 PMCID: PMC10522397 DOI: 10.18632/aging.204982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 07/17/2023] [Indexed: 09/06/2023]
Abstract
Liver transplant (LT) candidates have become older and frailer, with growing Non-alcoholic steatohepatitis (NASH) and comorbid disease burden in recent years, predisposing them for poor waitlist outcomes. We aimed to evaluate the impact of access to living donor liver transplantation (LDLT) in waitlisted patients at highest risk of dropout. We reviewed all adult patients with decompensated cirrhosis listed for LT from November 2012 to December 2018. Patients with a potential living donor (pLD) available were identified. Survival analyses with Cox Proportional Hazards models and time to LT with Competing risk models were performed followed by prediction model development. Out of 860 patients who met inclusion criteria, 360 (41.8%) had a pLD identified and 496 (57.6%) underwent LT, out of which 170 (34.2%) were LDLT. The benefit of pLD was evident for all, but patients with moderate to severe frailty at listing (interaction p = 0.03), height <160 cm (interaction p = 0.03), and Model for end stage liver disease (MELD)-Na score <20 (interaction p < 0.0001) especially benefited. Our prediction model identified patients at highest risk of dropout while waiting for deceased donor and most benefiting of pLD (time-dependent area under the receiver operating characteristic curve 0.82). Access to LDLT in a transplant program can optimize the timing of transplant for the increasingly older, frail patient population with comorbidities who are at highest risk of dropout.
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Affiliation(s)
- Fakhar Ali Qazi Arisar
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
- National Institute of Liver and GI Diseases, Dow University of Health Sciences, Karachi, Sindh 75330, Pakistan
| | - Shiyi Chen
- Department of Biostatistics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario M5G 2C1, Canada
| | - Catherine Chen
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
| | - Noorulsaba Shaikh
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
| | - Ravikiran Sindhuvalada Karnam
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario M5G 2C1, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario M5G 2C1, Canada
| | - Sumeet K. Asrani
- Division of Hepatology, Department of Medicine, Baylor University Medical Center, Dallas, TX 75246, USA
| | - Zita Galvin
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
| | - Gideon Hirschfield
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2C4, Canada
| | - Keyur Patel
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2C4, Canada
| | - Cynthia Tsien
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
| | - Nazia Selzner
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
| | - Mark Cattral
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario M5G 2N2, Canada
| | - Leslie Lilly
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
| | - Mamatha Bhat
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario M5G 2N2, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario M5G 2N2, Canada
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22
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Nathiya D, Raj P, Singh P, Bareth H, Tejavath AS, Suman S, Tomar BS, Rai RR. Frailty Predicting Health-Related Quality of Life Trajectories in Individuals with Sarcopenia in Liver Cirrhosis: Finding from BCAAS Study. J Clin Med 2023; 12:5348. [PMID: 37629390 PMCID: PMC10455585 DOI: 10.3390/jcm12165348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/28/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
The association between frailty and health-related quality of life (HRQoL) among Asian patients with liver cirrhosis and sarcopenia remains largely unexplored. To address this knowledge gap, we conducted a cross-sectional study involving individuals aged 32 to 69 years, all diagnosed with liver cirrhosis. The chronic liver disease questionnaire (CLDQ) was used to assess HR-QoL, the CLDQ score was used as an outcome to measure the factors related to HR-QoL, and the liver frailty index (LFI) was used to assess the frailty status. The association between the frailty status and the CLDQ summary scales was investigated using the correlation coefficient and multiple regression analyses. A total of 138 patients in the frail (n = 62) and non-frail (n = 76) groups with (alcohol: 97; viral: 24; autoimmune: 17; and cryptogenic: 12) were included in the study. Age, CTP score, and model for end-stage liver disease (MELD) sodium were significantly higher in the frail group. In the CLDQ domains, there was a significant difference between the frail and non-frail groups (p value = 0.001). In health-related quality-of-life summary measures, there was a strong negative correlation between frailty and the scores for activities, emotional function, and fatigue (p value = 0.001). When comparing frail to non-frail patients, these characteristics demonstrated significantly increased odds as indicated by their adjusted odds ratios: OR 3.339 (p value = 0.013), OR 3.998 (p value = 0.006), and OR 4.626 (p value = 0.002), respectively.
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Affiliation(s)
- Deepak Nathiya
- Department of Pharmacy Practice, Institute of Pharmacy, Nims University, Jaipur 303121, Rajasthan, India; (D.N.); (P.R.); (H.B.); (S.S.); (B.S.T.)
| | - Preeti Raj
- Department of Pharmacy Practice, Institute of Pharmacy, Nims University, Jaipur 303121, Rajasthan, India; (D.N.); (P.R.); (H.B.); (S.S.); (B.S.T.)
| | - Pratima Singh
- Department of Pharmacy Practice, Institute of Pharmacy, Nims University, Jaipur 303121, Rajasthan, India; (D.N.); (P.R.); (H.B.); (S.S.); (B.S.T.)
- School of Public Health, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Hemant Bareth
- Department of Pharmacy Practice, Institute of Pharmacy, Nims University, Jaipur 303121, Rajasthan, India; (D.N.); (P.R.); (H.B.); (S.S.); (B.S.T.)
| | - Arun Singh Tejavath
- Department of Gastroenterology, National Institute of Medical Science, Nims University, Jaipur 303121, Rajasthan, India; (A.S.T.); (R.R.R.)
| | - Supriya Suman
- Department of Pharmacy Practice, Institute of Pharmacy, Nims University, Jaipur 303121, Rajasthan, India; (D.N.); (P.R.); (H.B.); (S.S.); (B.S.T.)
| | - Balvir Singh Tomar
- Department of Pharmacy Practice, Institute of Pharmacy, Nims University, Jaipur 303121, Rajasthan, India; (D.N.); (P.R.); (H.B.); (S.S.); (B.S.T.)
- Department of Gastroenterology, National Institute of Medical Science, Nims University, Jaipur 303121, Rajasthan, India; (A.S.T.); (R.R.R.)
- Institute of Pediatric Gastroenterology and Hepatology, Nims University, Jaipur 303121, Rajasthan, India
| | - Ramesh Roop Rai
- Department of Gastroenterology, National Institute of Medical Science, Nims University, Jaipur 303121, Rajasthan, India; (A.S.T.); (R.R.R.)
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23
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Deng Y, Hui Y, Cui B, Xie W, Sun C. Accumulating awareness on the clinical significance and relevance of frailty in cirrhosis: Time to dig deeper into mechanistic basis! Liver Int 2023; 43:1629-1643. [PMID: 37288711 DOI: 10.1111/liv.15639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 04/03/2023] [Accepted: 05/25/2023] [Indexed: 06/09/2023]
Abstract
Frailty corresponds to an emerging construct in the hepatology which is originally introduced as a validated geriatric syndrome regarding increased vulnerability to pathophysiological stressors. As for patients with cirrhosis, the presence of frailty is indicative of debilitating conditions that subjects are prone to deleterious acute insults and have difficulties to restore even if the underlying liver function partially returned to normal levels. Since this conceptual development, a variety of tools assessing frailty have been proposed and evaluated in the context of cirrhosis. A recent performance-based metric for frailty, designated as Liver Frailty Index, has broadly been applied in patients with cirrhosis and exhibited acceptable predictive ability in relation to disease progression, mortality and hospitalization. However, those functional tests measuring frailty may be impossible to perform in circumstance that patients are critically ill or undergoing detrimental events. An interesting modality indicates the use of alternative tests to evaluate frailty, which may be more adaptable and of choice for specific subgroups. The interrelation between frailty and various cirrhosis-associated pathological entities is of clinical importance and implication. Noticeably, it is imperative to clarify these complex linkages to highlight novel therapeutic targets or interventional endpoints. The efficient and effective management of frailty is still challenging, but many attempts have been made to overcome barriers of affordability and availability. Some clinical trials on small scale revealed that home-based exercise and individualized nutrition therapy show benefits in patients with cirrhosis, and high adherence to the treatment regimen may direct better efficacy and performance.
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Affiliation(s)
- You Deng
- Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Binxin Cui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Wen Xie
- Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
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24
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Vogliotti E, Ceolin C, Valenti M, Vanin J, Campodall'Orto C, Tonon M, Zanforlini BM, Curreri C, Devita M, De Rui M, Coin A, Cillo U, Burra P, Angeli P, Sergi G. Can the Multidimensional Prognostic Index (MPI) be a predictive instrument for mortality in older adult liver transplant candidates? Eur Geriatr Med 2023; 14:851-859. [PMID: 37460836 PMCID: PMC10447597 DOI: 10.1007/s41999-023-00826-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/19/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE The most recent guidelines recommend that selection of liver transplant recipient patients be guided by a multidimensional approach that includes frailty assessment. Different scales have been developed to identify frail patients and determine their prognosis, but the data on older adult candidates are still inconclusive. The aim of this study was to compare the accuracy of the Liver Frailty Index (LFI) and the Multidimensional Prognostic Index (MPI) as predictors of mortality in a cohort of older people patients being evaluated for liver transplantation. METHODS This retrospective study was conducted on 68 patients > 70 years being followed at the University Hospital of Padua in 2018. Clinical information on each patient, Model For End-Stage Liver Disease (MELD), Body Mass Index (BMI), Activities of Daily Living (ADL), Mini Nutritional Assessment (MNA), LFI, MPI, and date-of-death, were recorded. The observational period was 3 years. RESULTS We studied 68 individuals (25 women), with a mean age 72.21 ± 1.64 years. Twenty-five (36.2%) patients died during the observational period. ROC curve analysis showed both MPI and LFI to be good predictors of mortality (AUC 0.7, p = 0.007, and AUC 0.689, p = 0.015, respectively). MELD (HR 1.99, p = 0.001), BMI (HR 2.34, p = 0.001), and poor ADL (HR 3.34, p = 0.04) were risk factors for mortality in these patients, while male sex (HR 0.1, p = 0.01) and high MNA scores (HR 0.57, p = 0.01) were protective factors. CONCLUSION Our study confirmed the prognostic value of MPI in older adult patients awaiting liver transplantation. In this cohort, good nutritional status and male sex were protective factors, while high MELD and BMI scores and poor functional status were risk factors.
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Affiliation(s)
- Edoardo Vogliotti
- Division of Geriatrics, Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Chiara Ceolin
- Division of Geriatrics, Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy.
| | - Matteo Valenti
- Division of Geriatrics, Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Jessica Vanin
- Division of Geriatrics, Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Carlotta Campodall'Orto
- Division of Geriatrics, Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Marta Tonon
- Internal Medicine and Hepatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | | | - Chiara Curreri
- Division of Geriatrics, University Hospital of Padua, Padua, Italy
| | - Maria Devita
- Department of General Psychology (DPG), University of Padua, Padua, Italy
- Division of Geriatrics, Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Marina De Rui
- Division of Geriatrics, University Hospital of Padua, Padua, Italy
| | - Alessandra Coin
- Division of Geriatrics, Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy
| | - Paolo Angeli
- Internal Medicine and Hepatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Giuseppe Sergi
- Division of Geriatrics, Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
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25
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Ravaioli F, De Maria N, Di Marco L, Pivetti A, Casciola R, Ceraso C, Frassanito G, Pambianco M, Pecchini M, Sicuro C, Leoni L, Di Sandro S, Magistri P, Menozzi R, Di Benedetto F, Colecchia A. From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients. Nutrients 2023; 15:2778. [PMID: 37375682 DOI: 10.3390/nu15122778] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/04/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Liver transplantation (LT) is a complex surgical procedure requiring thorough pre- and post-operative planning and care. The nutritional status of the patient before, during, and after LT is crucial to surgical success and long-term prognosis. This review aims to assess nutritional status assessment and management before, during, and after LT, with a focus on patients who have undergone bariatric surgery. We performed a comprehensive topic search on MEDLINE, Ovid, In-Process, Cochrane Library, EMBASE, and PubMed up to March 2023. It identifies key factors influencing the nutritional status of liver transplant patients, such as pre-existing malnutrition, the type and severity of liver disease, comorbidities, and immunosuppressive medications. The review highlights the importance of pre-operative nutritional assessment and intervention, close nutritional status monitoring, individualised nutrition care plans, and ongoing nutritional support and monitoring after LT. The review concludes by examining the effect of bariatric surgery on the nutritional status of liver transplant recipients. The review offers valuable insights into the challenges and opportunities for optimising nutritional status before, during, and after LT.
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Affiliation(s)
- Federico Ravaioli
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Nicola De Maria
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Lorenza Di Marco
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Alessandra Pivetti
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Riccardo Casciola
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Carlo Ceraso
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Gabriella Frassanito
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Martina Pambianco
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Maddalena Pecchini
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Chiara Sicuro
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Laura Leoni
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Renata Menozzi
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Antonio Colecchia
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
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26
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Tandon P, Zanetto A, Piano S, Heimbach JK, Dasarathy S. Liver transplantation in the patient with physical frailty. J Hepatol 2023; 78:1105-1117. [PMID: 37208097 PMCID: PMC10825673 DOI: 10.1016/j.jhep.2023.03.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/23/2023] [Accepted: 03/26/2023] [Indexed: 05/21/2023]
Abstract
Frailty is a decline in functional reserve across multiple physiological systems. A key component of frailty is sarcopenia, which denotes a loss of skeletal muscle mass and impaired contractile function that ultimately result in physical frailty. Physical frailty/sarcopenia are frequent and contribute to adverse clinical outcomes before and after liver transplantation. Frailty indices, including the liver frailty index, focus on contractile dysfunction (physical frailty), while cross-sectional image analysis of muscle area is the most accepted and reproducible measure to define sarcopenia. Thus, physical frailty and sarcopenia are interrelated. The prevalence of physical frailty/sarcopenia is high in liver transplant candidates and these conditions have been shown to adversely impact clinical outcomes including mortality, hospitalisations, infections, and cost of care both before and after transplantation. Data on the prevalence of frailty/sarcopenia and their sex- and age-dependent impact on outcomes are not consistent in patients on the liver transplant waitlist. Physical frailty and sarcopenic obesity are frequent in the obese patient with cirrhosis, and adversely affect outcomes after liver transplantation. Nutritional interventions and physical activity remain the mainstay of management before and after transplantation, despite limited data from large scale trials. In addition to physical frailty, there is recognition that a global evaluation including a multidisciplinary approach to other components of frailty (e.g., cognition, emotional, psychosocial) also need to be addressed in patients on the transplant waitlist. Recent advances in our understanding of the underlying mechanisms of sarcopenia and contractile dysfunction have helped identify novel therapeutic targets.
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Affiliation(s)
- Puneeta Tandon
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED, University and Hospital of Padova, Padova, Italy
| | - Julie K Heimbach
- William J von Liebig Transplant Center Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, USA
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27
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Siramolpiwat S, Limthanetkul N, Pornthisarn B, Vilaichone RK, Chonprasertsuk S, Bhanthumkomol P, Nunanan P, Issariyakulkarn N. Branched-chain amino acids supplementation improves liver frailty index in frail compensated cirrhotic patients: a randomized controlled trial. BMC Gastroenterol 2023; 23:154. [PMID: 37189033 DOI: 10.1186/s12876-023-02789-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/26/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Physical frailty is related with morbidity and mortality in patients with cirrhosis. Currently, there is no approved treatment of frailty in these patients. Here, we evaluated the efficacy of 16 weeks branched-chain amino acids (BCAA) supplementation on frailty in frail compensated cirrhotic patients. METHODS After a 4-week run-in period consisted of dietary and exercise counseling, compensated cirrhotic patients with frailty, defined by liver frailty index (LFI)≥4.5, were randomly assigned (1:1) to BCAA or control group. The BCAA group received twice daily BCAAs supplementation (210 kcal, protein 13.5 g, BCAA 2.03 g) for 16 weeks. The primary outcome was frailty reversion. The secondary outcomes were changes in biochemistries, body composition evaluated by bioelectrical impedance analysis, and quality of life (QoL). RESULTS 54 patients were prospectively enrolled (age 65.5 ± 9.9 years, 51.9% female, Child-Pugh A/B 68.5%/31.5%, MELD 10.3 ± 3.1). Baseline characteristics were similar between both groups. At week 16, BCAA group had a significant improvement in LFI (-0.36 ± 0.3 vs. -0.15 ± 0.28, P = 0.01), BMI (+ 0.51 ± 1.19 vs. -0.49 ± 1.89 kg/m2, P = 0.03), and serum albumin (+ 0.26 ± 0.27 vs. +0.06 ± 0.3 g/dl, P = 0.01). The proportion of frailty reversion at week 16 was significantly higher in BCAA group (36% vs. 0%, P < 0.001). Compared with baseline, BCAA group had a significant increase in skeletal muscle index (7.5 ± 1.6 to 7.8 ± 1.5 kg/m2, P = 0.03). Regarding the QoL, only the BCAA group had a significant improvement in all 4 domains of physical component score of the SF-36 questionnaire. CONCLUSIONS A 16-week BCAA supplementation improved frailty in frail compensated cirrhotic patients. In addition, this intervention resulted in an improvement of muscle mass and physical domain of QoL in these patients. TRIAL REGISTRATION This study was registered with Thai Clinical Trial Registry (TCTR20210928001; https://www.thaiclinicaltrials.org/# ).
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Affiliation(s)
- Sith Siramolpiwat
- Chulabhorn International College of Medicine, Thammasat University, Pathum Thani, Thailand.
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand.
| | - Nisakorn Limthanetkul
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Bubpha Pornthisarn
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Ratha-Korn Vilaichone
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Soonthorn Chonprasertsuk
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Patommatat Bhanthumkomol
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Pongjarat Nunanan
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Navapan Issariyakulkarn
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
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28
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Wang M, Shui AM, Barry F, Verna E, Kent D, Yao F, Seetharaman S, Berry K, Grubbs RK, George G, Huang CY, Duarte-Rojo A, Lai JC. The TeLeFI (Tele-Liver Frailty Index): Development of a novel frailty tool in patients with cirrhosis via telemedicine. Am J Transplant 2023:S1600-6135(23)00409-4. [PMID: 37061188 DOI: 10.1016/j.ajt.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/23/2023] [Accepted: 04/10/2023] [Indexed: 04/17/2023]
Abstract
Frailty is a critical determinant of outcomes in cirrhosis patients. Increasing use of telemedicine has created an unmet need for virtual frailty assessment. We aimed to develop a telemedicine-enabled frailty tool [tele-Liver Frailty Index (TeLeFI)]. Adults with cirrhosis in the liver transplant (LT) setting underwent ambulatory frailty testing with the Liver Frailty Index (LFI) in-person, then virtual administration of: 1) validated surveys [e.g., SARC-F, Duke Activity Status Index (DASI)], 2) chair stands, 3) balance. Two models were selected and internally validated for predicting LFI≥4.4 using: 1) Bayesian information criterion (BIC), 2) C-statistics, and 3) ease of use. Of 145 patients, median [IQR] LFI was 3.7 (3.3-4.2); 15% were frail. Frail (vs. not-frail) patients reported significantly greater impairment on all virtually assessed instruments. We selected 2 parsimonious models: 1) DASI + chair/bed transfer (SARC-F) [BIC 255, C-statistics 0.78], and 2) DASI + chair/bed transfer (SARC-F) + virtually assessed chair stands (BIC 244, C-statistics 0.79). Both models had high C-statistics (0.76-0.78) for predicting frailty. In conclusion, the TeLeFI is a novel tool to pragmatically screen frailty in LT patients via telemedicine and may be used to identify patients who require in-person frailty assessment, more frequent follow-up, or frailty intervention.
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Affiliation(s)
- Melinda Wang
- Department of Medicine, University of California- San Francisco, San Francisco, CA
| | - Amy M Shui
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | - Fawzy Barry
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Elizabeth Verna
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Dorothea Kent
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Frederick Yao
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Srilakshmi Seetharaman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Kacey Berry
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA
| | - Rachel K Grubbs
- Columbia University Irving Medical Center, New York, NY, United States
| | - Geena George
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA
| | | | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, CA.
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Frailty as tested by the Liver Frailty Index in out-patient patients with cirrhosis in China: a cross-sectional study. Eur J Gastroenterol Hepatol 2023; 35:440-444. [PMID: 36538009 DOI: 10.1097/meg.0000000000002502] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND Early identification and prevention of frailty are very important for patients with cirrhosis. METHODS The study was the first to use Liver Frailty Index in out-patient patients with cirrhosis in China, and to analyze the influencing factors. RESULT This study included 387 patients with cirrhosis. Frailty was diagnosed using the Liver Frailty Index. Multiple Logistic regression model were used to analyze influencing factors of frailty in out-patient patients with cirrhosis. Frailty was diagnosed in 9.6% of patients and prefrailty was diagnosed in 54.8% of patients. Age, sex, BMI, education level, monthly economic income, number of unplanned hospital admissions in the past year, cause of cirrhosis, Child-Pugh classification of cirrhosis, nutritional risk, physical activity, gait speed and Activity of Daily Living (ADL) Scale in the frailty, prefrailty and no frailty of groups were statistically significant. Age (OR, 1.103; CI, 0.064-0.132), BMI (OR, 0.817; CI, -0.302 to -0.104), education level (OR, 4.321; CI, 0.754-2.173), physical activity (OR, 3.580; CI, 0.534-2.016) and gait speed (OR, 0.001; CI, -8.188 to -4.972) were influential factors of frailty in out-patient patients with cirrhosis. CONCLUSION Out-patient patients with cirrhosis have a high incidence of frailty and prefrailty. Elderly, reduced gait speed, no physical activity and low culture level are risk factors for frailty and prefrailty, and we should be identification and intervention early.
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Jesse MT, Jackson WE, Liapakis A, Ganesh S, Humar A, Goldaracena N, Levitsky J, Mulligan D, Pomfret EA, Ladner DP, Roberts JP, Mavis A, Thiessen C, Trotter J, Winder GS, Griesemer AD, Pillai A, Kumar V, Verna EC, LaPointe Rudow D, Han HH. Living donor liver transplant candidate and donor selection and engagement: Meeting report from the living donor liver transplant consensus conference. Clin Transplant 2023:e14954. [PMID: 36892182 DOI: 10.1111/ctr.14954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/14/2023] [Accepted: 02/25/2023] [Indexed: 03/10/2023]
Abstract
INTRODUCTION Living donor liver transplantation (LDLT) is a promising option for mitigating the deceased donor organ shortage and reducing waitlist mortality. Despite excellent outcomes and data supporting expanding candidate indications for LDLT, broader uptake throughout the United States has yet to occur. METHODS In response to this, the American Society of Transplantation hosted a virtual consensus conference (October 18-19, 2021), bringing together relevant experts with the aim of identifying barriers to broader implementation and making recommendations regarding strategies to address these barriers. In this report, we summarize the findings relevant to the selection and engagement of both the LDLT candidate and living donor. Utilizing a modified Delphi approach, barrier and strategy statements were developed, refined, and voted on for overall barrier importance and potential impact and feasibility of the strategy to address said barrier. RESULTS Barriers identified fell into three general categories: 1) awareness, acceptance, and engagement across patients (potential candidates and donors), providers, and institutions, 2) data gaps and lack of standardization in candidate and donor selection, and 3) data gaps regarding post-living liver donation outcomes and resource needs. CONCLUSIONS Strategies to address barriers included efforts toward education and engagement across populations, rigorous and collaborative research, and institutional commitment and resources.
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Affiliation(s)
- Michelle T Jesse
- Transplant Institute, Henry Ford Health System, Detroit, Michigan, USA
| | - Whitney E Jackson
- Division of Gastroenterology and Hepatology, University of Colorado, Aurora, Colorado, USA
| | - AnnMarie Liapakis
- Yale School of Medicine and Yale New Haven Transplant Center, New Haven, Connecticut, USA
| | - Swaytha Ganesh
- Thomas E Starzl Transplant Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Abhinav Humar
- Thomas E Starzl Transplant Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nicolas Goldaracena
- Division of Transplant Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Josh Levitsky
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David Mulligan
- Division of Transplant Surgery, Yale University, New Haven, Connecticut, USA
| | | | - Daniela P Ladner
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John P Roberts
- UCSF Department of Surgery, San Francisco, California, USA
| | - Alisha Mavis
- Pediatric Gastroenterology, Hepatology, and Nutrition, Duke University Health, Durham, North Carolina, USA
| | - Carrie Thiessen
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - James Trotter
- Transplant Hepatology, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Adam D Griesemer
- Department of Surgery, NYU Langone Heath, New York, New York, USA
| | - Anjana Pillai
- Department of Internal Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Vineeta Kumar
- Department of Medicine, Division of Nephrology/Transplant, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University, New York, New York, USA
| | - Dianne LaPointe Rudow
- Recanati/Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
| | - Hyosun H Han
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Worden A, Pike F, Allegretti AS, Kaur H, Peng JL, Kettler CD, Orman ES, Desai AP, Nephew LD, Ghabril MS, Patidar KR. The prognostic impact of acute kidney injury recovery patterns in critically ill patients with cirrhosis. Liver Transpl 2023; 29:246-258. [PMID: 36811876 PMCID: PMC10068809 DOI: 10.1097/lvt.0000000000000008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/11/2022] [Indexed: 02/24/2023]
Abstract
BACKGROUND The prognostic impact of acute kidney injury (AKI) recovery patterns in critically ill patients with cirrhosis is unknown. We aimed to compare mortality stratified by AKI recovery patterns and identify predictors of mortality in patients with cirrhosis and AKI admitted to the intensive care unit. MATERIALS AND METHODS Patients with cirrhosis and AKI from 2016 to 2018 at 2 tertiary care intensive care units were analyzed (N=322). AKI recovery was defined by Acute Disease Quality Initiative consensus: return of serum creatinine <0.3 mg/dL of baseline within 7 days of AKI onset. Recovery patterns were categorized by Acute Disease Quality Initiative consensus: 0-2 days, 3-7 days, and no-recovery (persistence of AKI >7 d). Landmark competing risk univariable and multivariable models (liver transplant as competing risk) was used to compare 90-day mortality between AKI recovery groups and to determine independent predictors of mortality. RESULTS Sixteen percent (N=50) and 27% (N=88) achieved AKI recovery within 0-2 and 3-7 days, respectively; 57% (N=184) had no-recovery. Acute on chronic liver failure was prevalent (83%) and patients with no-recovery were more likely to have grade 3 acute on chronic liver failure (N=95, 52%) compared to patients with AKI recovery [0-2: 16% (N=8); 3-7: 26% (N=23); p<0.001]. Patients with no-recovery had significantly higher probability of mortality [unadjusted-sub-HR (sHR): 3.55; 95% CI: 1.94-6.49; p<0.001] compared to patients with recovery within 0-2 days, while the probability was similar between 3-7 and 0-2 days (unadjusted-sub-HR: 1.71; 95% CI: 0.91-3.20; p=0.09). On multivariable analysis, AKI no-recovery (sub-HR: 2.07; 95% CI: 1.33-3.24; p=0.001), severe alcohol-associated hepatitis (sub-HR: 2.41; 95% CI: 1.20-4.83; p=0.01), and ascites (sub-HR: 1.60; 95% CI: 1.05-2.44; p=0.03) were independently associated with mortality. CONCLUSION AKI no-recovery occurs in over half of critically ill patients with cirrhosis and AKI and is associated with worse survival. Interventions that facilitate AKI recovery may improve outcomes in this patient population.
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Affiliation(s)
- Astin Worden
- Division of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Francis Pike
- Department of Biostatistics, Indiana University, Indianapolis, Indiana, USA
| | - Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Harleen Kaur
- Division of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jennifer L. Peng
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Carla D. Kettler
- Department of Biostatistics, Indiana University, Indianapolis, Indiana, USA
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan S. Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kavish R. Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Mao L, Li C, Wang X, Sun M, Li Y, Yu Z, Cui B, Guo G, Yang W, Hui Y, Fan X, Zhang J, Jiang K, Sun C. Dissecting the Contributing Role of Divergent Adipose Tissue to Multidimensional Frailty in Cirrhosis. J Clin Transl Hepatol 2023; 11:58-66. [PMID: 36406322 PMCID: PMC9647104 DOI: 10.14218/jcth.2022.00027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/01/2022] [Accepted: 04/05/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND AIMS Emerging evidence has demonstrated that abnormal body composition may potentiate the development of frailty, whereas little work focuses on the role of divergent adipose tissue. Therefore, we aimed to determine the potential contribution of adipose tissue distribution to multidimensional frailty in decompensated cirrhosis. METHODS We conducted a retrospective cohort study. Divergent adipose tissues were assessed by computed tomography-derived subcutaneous adipose tissue index (SATI), visceral adipose tissue index (VATI) and total adipose tissue index (TATI), respectively. Frailty was identified by our validated self-reported Frailty Index. Multiple binary logistic models incorporating different covariates were established to assess the relationship between adipose tissue distribution and frailty. RESULTS The study cohort comprised 245 cirrhotic patients with 45.3% being male. The median Frailty Index, body mass index (BMI) and model for end-stage liver disease (MELD) score were 0.11, 24.3 kg/m2 and 8.9 points, respectively. In both men and women, patients who were frail exhibited lower levels of SATI in comparison with nonfrail patients. SATI inversely correlated with Frailty Index in the entire cohort (rs=-0.1361, p=0.0332). Furthermore, SATI or TATI was independently associated with frail phenotype in several multiple logistic regression models adjusting for age, BMI, presence of ascites, sodium, Child-Pugh class or MELD score in isolation. CONCLUSIONS In the context of decompensated cirrhosis, low SATI and concomitant TATI were associated with higher risk of being frail. These findings highlight the importance to further apply tissue-specific tools of body composition in place of crude metric like BMI.
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Affiliation(s)
- Lihong Mao
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Chaoqun Li
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Internal Medicine, Tianjin Hexi Hospital, Tianjin, China
| | - Xiaoyu Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Mingyu Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Yifan Li
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Zihan Yu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Binxin Cui
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Gaoyue Guo
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Wanting Yang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaofei Fan
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Jie Zhang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Kui Jiang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
- Correspondence to: Kui Jiang and Chao Sun, Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin 300052, China. ORCID: https://orcid.org/0000-0002-0380-7999 (CS). Tel: +86-22-60362608, Fax: +86-22-27813550, E-mail: (KJ) and (CS)
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
- Correspondence to: Kui Jiang and Chao Sun, Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin 300052, China. ORCID: https://orcid.org/0000-0002-0380-7999 (CS). Tel: +86-22-60362608, Fax: +86-22-27813550, E-mail: (KJ) and (CS)
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Sarcopenia and Frailty in Cirrhosis. Med Clin North Am 2023; 107:589-604. [PMID: 37001955 DOI: 10.1016/j.mcna.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Sarcopenia and frailty are frequent in cirrhosis, and both contribute to increased morbidity and mortality. The complex pathogenesis of sarcopenia in cirrhosis is mainly determined by hyperammonemia and malnutrition. Sarcopenia/frailty screening and reevaluation should be undertaken in all cirrhotic patients. Frailty tests are useful in the ambulatory setting, whereas the computed tomography scan is the diagnostic gold standard for sarcopenia. To manage sarcopenia/frailty, a multidisciplinary team should develop a personalized comprehensive care plan that includes patient education, protein/calorie intake goals, late evening meals, exercise programs, and micronutrient replenishment. In selected patients, branched-chain amino acid and testosterone supplements may also be beneficial.
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Lai JC, Shui AM, Duarte-Rojo A, Rahimi RS, Ganger DR, Verna EC, Volk ML, Kappus M, Ladner DP, Boyarsky B, Segev DL, Gao Y, Huang CY, Singer JP. Association of Frailty With Health-Related Quality of Life in Liver Transplant Recipients. JAMA Surg 2023; 158:130-138. [PMID: 36515937 PMCID: PMC9856900 DOI: 10.1001/jamasurg.2022.6387] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 08/23/2022] [Indexed: 12/15/2022]
Abstract
Importance Frailty has been recognized as a risk factor for mortality after liver transplant (LT) but little is known of its association with functional status and health-related quality of life (HRQL), termed global functional health, in LT recipients. Objective To evaluate the association between pre-LT and post-LT frailty with post-LT global functional health. Design, Setting, and Participants This prospective cohort study was conducted at 8 US LT centers and included adults who underwent LT from October 2016 to February 2020. Exposures Frail was defined by a pre-LT Liver Frailty Index (LFI) score of 4.5 or greater. Main Outcomes and Measures Global functional health at 1 year after LT, assessed using surveys (Short Form-36 [SF-36; summarized by physical component scores (PFC) and mental component summary scores (MCS)], Instrumental Activities of Daily Living scale) and performance-based tests (LFI, Fried Frailty Phenotype, and Short Physical Performance Battery). Results Of 358 LT recipients (median [IQR] age, 60 [53-65] years; 115 women [32%]; 25 [7%] Asian/Pacific Islander, 21 [6%] Black, 54 [15%] Hispanic White, and 243 [68%] non-Hispanic White individuals), 68 (19%) had frailty pre-LT. At 1 year post-LT, the median (IQR) PCS was lower in recipients who had frailty vs those without frailty pre-LT (42 [31-53] vs 50 [38-56]; P = .002), but the median MCS was similar. In multivariable regression, pre-LT frailty was associated with a -5.3-unit lower post-LT PCS (P < .001), but not MCS. The proportion who had difficulty with 1 or more Instrumental Activities of Daily Living (21% vs 10%) or who were unemployed/receiving disability (38% vs 29%) was higher in recipients with vs without frailty. In a subgroup of 210 recipients with LFI assessments 1 year post-LT, 13% had frailty at 1 year post-LT. Recipients who had frailty post-LT reported lower adjusted SF-36-PCS scores (coefficient, -11.4; P < .001) but not SF-36-MCS scores. Recipients of LT who had frailty vs those without frailty 1 year post-LT also had worse median (IQR) Fried Frailty Phenotype scores (1 [1-2] vs 1 [0-1]) and higher rates of functional impairment by a Short Physical Performance Battery of 9 or less (42% vs 20%; P = .01). Conclusions and Relevance In this cohort study, pre-LT frailty was associated with worse global functional health 1 year after LT. The presence of frailty after LT was also associated with worse HRQL in physical, but not mental, subdomains. These data suggest that interventions and therapeutics that target frailty that are administered before and/or early post-LT may help to improve the health and well-being of LT recipients.
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Affiliation(s)
- Jennifer C. Lai
- Department of Medicine, University of California, San Francisco
| | - Amy M. Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Andres Duarte-Rojo
- Center for Liver Diseases, Thomas A. Starzl Transplantation Institute, Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert S. Rahimi
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Baylor Scott and White Health, Dallas, Texas
| | - Daniel R. Ganger
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Medicine, Chicago, Illinois
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York
| | - Michael L. Volk
- Division of Gastroenterology & Hepatology, and Transplantation Institute, Loma Linda University Health, Loma Linda, California
| | - Matthew Kappus
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Daniela P. Ladner
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Transplantation, Department of Surgery, Northwestern Medicine, Chicago, Illinois
| | - Brian Boyarsky
- New York University Grossman School of Medicine, New York
| | - Dorry L. Segev
- New York University Grossman School of Medicine, New York
| | - Ying Gao
- Department of Medicine, University of California, San Francisco
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco
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Prognostic impact of the coexistence of hepato-renal dysfunction and frailty in patients with heart failure. J Cardiol 2023; 81:215-221. [PMID: 36167755 DOI: 10.1016/j.jjcc.2022.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/01/2022] [Accepted: 08/27/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Complex multi-organ interactions such as coexistence of hepato-renal dysfunction in heart failure (HF) adversely affects patient prognosis. However, the association between liver/kidney dysfunction and frailty and effects of their coexistence on HF prognosis remain unclear. METHODS This retrospective cohort study included 922 patients with HF (median age, 72 years; interquartile range: 62-79 years). All patients underwent hepato-renal function testing using the model for end-stage liver disease, excluding international normalized ratio (MELD-XI) score and frailty score. Frailty was measured using a composite of four markers: handgrip strength, gait speed, serum albumin, and activities of daily living status, combined into a total frailty score (range 0-12). Patients were assigned to a frailty score <5 (without frailty) or ≥5 (frailty) group. The multivariable logistic regression model was used to analyze the association between MELD-XI score and frailty; the prognostic value of high MELD-XI score and frailty coexistence was investigated. The endpoint was all-cause mortality. RESULTS After adjusting for covariates and dividing by the median MELD-XI score, the high MELD-XI score group [odds ratio: 1.663, 95 % confidence interval (CI): 1.200-2.304, p = 0.002] was significantly associated with frailty, compared with the low MELD-XI score group. One hundred and fifty deaths occurred during follow-up (median, 2.13 years; interquartile range, 0.93-4.09 years). Patients in the high MELD-XI score/frailty group had a significantly higher mortality risk, even after adjusting for HF severity (hazard ratio: 4.326, 95 % CI: 2.527-7.403, p < 0.001). CONCLUSIONS Hepato-renal dysfunction is associated with frailty in patients with HF, which affects patient prognosis. BRIEF SUMMARY This study showed that hepato-renal dysfunction in patients with HF, as assessed by the model for end-stage liver disease excluding international normalized ratio (MELD-XI) score, is associated with frailty, even after adjusting for factors involved in the frailty or severity of HF. Additionally, high MELD-XI score combined with frailty is associated with a poorer prognosis. These results suggest that hepato-renal dysfunction and frailty can be used for risk stratification in patients with HF.
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Annual changes in grip strength and skeletal muscle mass in chronic liver disease: observational study. Sci Rep 2023; 13:1648. [PMID: 36717617 PMCID: PMC9887068 DOI: 10.1038/s41598-023-28528-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/19/2023] [Indexed: 01/31/2023] Open
Abstract
Sarcopenia is a common complication in patients with chronic liver disease (CLD); however, the progression of sarcopenia over the course of CLD is unclear. The present study therefore determined the natural course of the progression of sarcopenia in patients with CLD and the effect of liver cirrhosis (LC) on this progression. This observational study analyzed patients with chronic hepatitis (CH) (n = 536) and LC (n = 320) who underwent evaluations of the grip strength and skeletal muscle mass of the arms, trunk, and legs for sarcopenia between 2016 and 2021. A bioelectrical impedance analysis was used to evaluate skeletal muscle mass. The annual rate of change (%/year) in two tests were compared between patients with CH and LC. The annual rates of change in grip strength and skeletal muscle of arms, trunk, and legs of patients with CH and LC were - 0.84% vs. - 2.93%, - 0.54% vs. - 1.71%, - 0.43% vs. - 1.02%, and - 0.76% vs. - 1.70% for men and - 0.12% vs. - 1.71%, - 0.66% vs. - 1.71%, - 0.49% vs. - 1.31%, and - 0.76% vs. - 1.54% for women, respectively. The progression of sarcopenia was greater in LC patients than in CH patients and that the decrease in grip strength was most prominent in the progression of sarcopenia in patients with LC.
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Moosavi SA, Mashhadiagha A, Taherifard E, Fallahzadeh MA, Motazedian N, Sayadi M, Azarpira N, Rahimi RS. Frailty as a predictor of poor outcomes among patients awaiting liver transplant: a systematic review and meta-analysis. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2023; 16:364-377. [PMID: 38313349 PMCID: PMC10835093 DOI: 10.22037/ghfbb.v16i4.2795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/07/2023] [Indexed: 02/06/2024]
Abstract
Aim This review sought to evaluate the significance of a functional assessment for liver transplant candidates, i.e., frailty, in the pre-transplant setting and its association with mortality and morbidities. Background Liver transplantation (LT) remains the treatment of choice for patients with end-stage liver disease. Due to the shortage of organs for LT, a careful selection of suitable recipients is essential. Frailty, a measure of physiologic reserve and increased vulnerability to stressors, was initially used in geriatrics and then introduced to the field of transplantation for better patient selection. Methods PubMed, Scopus, and Web of Science databases were reviewed up until January 2023. The search terms included: "frail*", "liver", and "transplant*". A Meta-analysis was conducted for the hazard ratios (HRs) obtained from the COX regression models. Fifty-five studies were included in this review; ten were included in the meta-analysis. Results The prevalence of frailty varied from 2.82% to 70.09% in the studies. Meta-analysis showed that overall frailty had a significant association with mortality (pooled adjusted HR [95%CI]: 2.66 [1.96-3.63]). Subgroup analyses revealed that both the Liver Frailty Index and Fried Frailty Index were significantly associated with mortality. Furthermore, these studies have demonstrated that this population's frailty is associated with ascites, hepatic encephalopathy, and esophageal varices. Conclusion According to emerging evidence, frailty is associated with increased morbidity and mortality of the patients on the LT waiting list. Further randomized trials are required to determine the efficacy and safety of variable interventions in the frail population.
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Affiliation(s)
- Seyed Ali Moosavi
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
- These authors contributed equally
| | - Amirali Mashhadiagha
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
- These authors contributed equally
| | - Erfan Taherifard
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Nasrin Motazedian
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrab Sayadi
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Negar Azarpira
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Robert S Rahimi
- Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, United States
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Powell EE, Stuart KA, Finnigan S, Hinson J, Bernardes CM, Hartel G, Valery PC. Low Prevalence of Use of Allied Health and Community Services for Patients with Cirrhosis in Australia: A Need for Greater Engagement. Patient Prefer Adherence 2023; 17:1117-1130. [PMID: 37102126 PMCID: PMC10124554 DOI: 10.2147/ppa.s405567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/22/2023] [Indexed: 04/28/2023] Open
Abstract
Background Psychosocial, lifestyle and practical needs are not routinely attended to during outpatient hepatology management, and little is known about the type and effectiveness of support services accessed by patients with cirrhosis. We quantified the type and use of community and allied health services in patients with cirrhosis. Methods The study included 562 Australian adults with a diagnosis of cirrhosis. Health service use was assessed via questionnaire and via linkage to the Australian Medicare Benefits Schedule. Patient needs were assessed using the Supportive Needs Assessment tool for Cirrhosis (SNAC). Results Although most patients (85.9%) used at least one community/allied health service for support with their liver disease, many reported requiring additional help with psychosocial (67.4%), lifestyle (34.3%) or practical needs (21.9%) that were not met by available services, or patients did not access services. A multidisciplinary care plan or case conference (in the 12 months prior to recruitment) was accessed by 48% of patients, 56.2% reported the use of a general practitioner for support with cirrhosis, and a dietician was the allied health clinician most accessed by patients (45.9%). Despite the high prevalence of psychosocial needs, there was relatively limited use of mental health and social work services (14.1% of patients reported the use of a psychologist), confirmed by a low prevalence of use of mental health services (17.7%) in the linked data. Conclusion Patients with cirrhosis who have unmet complex physical and psychosocial needs require better strategies to increase their engagement with allied health and community services.
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Affiliation(s)
- Elizabeth E Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Centre for Liver Disease Research, Faculty of Medicine, the University of Queensland, Woolloongabba, Queensland, Australia
| | - Katherine A Stuart
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Simon Finnigan
- Community and Oral Health, Metro North Health, Chermside, Queensland, Australia
| | - Jan Hinson
- Faculty of Health Sciences, School of Allied Health, Australian Catholic University, Banyo, Queensland, Australia
| | - Christina M Bernardes
- Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Gunter Hartel
- Statistics, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Patricia C Valery
- Centre for Liver Disease Research, Faculty of Medicine, the University of Queensland, Woolloongabba, Queensland, Australia
- Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
- Correspondence: Patricia C Valery, QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, Queensland, 4006, Australia, Tel +61 07 3362 0376, Email
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Towey J, Ngonadi C, Rajoriya N, Holt A, Greig C, Armstrong MJ. Protocol for a case-control prospective study to investigate the impact of Hepatic Encephalopathy on Nutritional Intake and Sarcopenia status in patients with end-stage LIVer disease: HENS-LIV study. BMJ Open Gastroenterol 2022; 9:bmjgast-2022-001052. [PMID: 36564096 PMCID: PMC9791380 DOI: 10.1136/bmjgast-2022-001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Hepatic encephalopathy (HE) is a debilitating symptom of end-stage liver disease (ESLD), but there remains a paucity of evidence regarding its impact on nutritional status, nutritional intake, compliance with nutritional support and resultant muscle health and function. Malnutrition and sarcopenia are associated with increased morbidity and mortality in patients with ESLD. The aim of the current case-control study is to prospectively investigate the impact of HE on nutritional intake and sarcopenia status in patients with ESLD. METHODS AND ANALYSIS Patients with ESLD, with HE (n=10) and without HE (n=10) will be recruited at the outpatient liver unit, University Hospital Birmingham, UK. All patients will undergo clinical assessment at baseline and again at 6-8 weeks (in-line with their routine clinical follow-up), to assess the impact of HE on reported nutritional intake, nutritional status and sarcopenia/physical functional status. Standard medical, dietetic and home-based exercise physiotherapy care will continue for all participants as determined by their clinical team. Two methods of assessing nutritional intake will include the 24-hour food recall and 3-day food diaries. Assessment of sarcopenia status will be undertaken using anthropometry (mid-arm muscle circumference (MAMC)) and ultrasound imaging of the quadriceps muscle group. Markers of physical function (hand grip strength; chair rise time), frailty (Liver Frailty Index (LFI)), physical activity (accelerometery) and exercise capacity (Duke Activity Status Index (DASI)) will be assessed at both clinic visits. ETHICS AND DISSEMINATION The study is approved by Wales Research Ethics Committee 2 and Health Research Authority (REC reference: 21/WA/0216). Recruitment into the study commenced November 2021. The findings will be disseminated through peer-reviewed publications and international presentations. TRIAL REGISTRATION NUMBER RRK7156.
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Affiliation(s)
- Jennifer Towey
- Department of Nutrition and Dietetics, Queen Elizabeth Hospital, Birmingham, UK,University of Birmingham, Birmingham, UK
| | | | - Neil Rajoriya
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Holt
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Chen M, Lu C, Zha J. Long Sleep Duration Increases the Risk of All-Cause Mortality Among Community-Dwelling Older Adults With Frailty: Evidence From NHANES 2009-2014. J Appl Gerontol 2022; 42:1078-1088. [PMID: 36560922 DOI: 10.1177/07334648221147917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objectives: The aim of this study was to determine the effect of sleep duration on all-cause mortality among older adults with frailty. Methods: The prospective cohort study included 5705 community participants aged 60 or above in the National Health and Nutrition Examination Survey (NHANES). Health indicators were selected in the NHANES to obtain the frailty index and sleep duration. The risk of all-cause mortality was estimated by a Cox proportional hazard model. Results: During the follow-up, long sleep duration was associated with higher all-cause mortality (adjusted HR = 1.28, 95% CI 1.03-1.59). The hazard of all-cause mortality was the lowest from the beginning of sleep until sleep duration reached 5.8 hours among older adults with frailty. Discussion: Long sleep duration was associated with higher all-cause mortality among older adults with frailty. There was a U-shaped relationship between sleep duration and all-cause mortality.
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Affiliation(s)
- Mingzhuang Chen
- Divison of Medical Affairs, 117556The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Chao Lu
- First Affiliated Hospital, 91594Anhui University of Science and Technology, Huainan, China
| | - Jingru Zha
- Office of Party, 117556The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
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Oikonomou IM, Sinakos E, Antoniadis N, Goulis I, Giouleme O, Anifanti M, Katsanos G, Karakasi KE, Tsoulfas G, Kouidi E. Effects of an active lifestyle on the physical frailty of liver transplant candidates. World J Transplant 2022; 12:365-377. [PMID: 36437844 PMCID: PMC9693895 DOI: 10.5500/wjt.v12.i11.365] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/26/2022] [Accepted: 10/18/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Liver transplantation is the most important therapeutic intervention for end-stage liver disease (ELD). The prioritization of these patients is based on the model for end-stage liver disease (MELD), which can successfully predict short-term mortality. However, despite its great validity and value, it cannot fully incorporate several comorbidities of liver disease, such as sarcopenia and physical frailty, variables that can sufficiently influence the survival of such patients. Subsequently, there is growing interest in the importance of physical frailty in regard to mortality in liver transplant candidates and recipients, as well as its role in improving their survival rates.
AIM To evaluate the effects of an active lifestyle on physical frailty on liver transplant candidates.
METHODS An observational study was performed within the facilities of the Department of Transplant Surgery of Aristotle University of Thessaloniki. Twenty liver transplant candidate patients from the waiting list of the department were included in the study. Patients that were bedridden, had recent cardiovascular incidents, or had required inpatient treatment for more than 5 d in the last 6 mo were excluded from the study. The following variables were evaluated: Activity level via the International Physical Activity Questionnaire (IPAQ); functional capacity via the 6-min walking test (6MWT) and cardiopulmonary exercise testing; and physical frailty via the Liver Frailty Index (LFI).
RESULTS According to their responses in the IPAQ, patients were divided into the following two groups based on their activity level: Active group (A, 10 patients); and sedentary group (S, 10 patients). Comparing mean values of the recorded variables showed the following results: MELD (A: 12.05 ± 5.63 vs S: 13.99 ± 3.60; P > 0.05); peak oxygen uptake (A: 29.78 ± 6.07 mL/kg/min vs S: 18.11 ± 3.39 mL/kg/min; P < 0.001); anaerobic threshold (A: 16.71 ± 2.17 mL/kg/min vs S: 13.96 ± 1.45 mL/kg/min; P < 0.01); 6MWT (A: 458.2 ± 57.5 m vs S: 324.7 ± 55.8 m; P < 0.001); and LFI (A: 3.75 ± 0.31 vs S: 4.42 ± 0.32; P < 0.001).
CONCLUSION An active lifestyle can be associated with better musculoskeletal and functional capacity, while simultaneously preventing the evolution of physical frailty in liver transplant candidates. This effect appears to be independent of the liver disease severity.
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Affiliation(s)
- Ilias Marios Oikonomou
- Department of Transplant Surgery, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Emmanouil Sinakos
- The Fourth Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Nikolaos Antoniadis
- Department of Transplant Surgery, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Ioannis Goulis
- The Fourth Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Olga Giouleme
- The Second Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Maria Anifanti
- Laboratory of Sports Medicine, Aristotle University of Thessaloniki, Thessaloniki 57001, Greece
| | - Georgios Katsanos
- Department of Transplant Surgery, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | | | - Georgios Tsoulfas
- Department of Transplant Surgery, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Evangelia Kouidi
- Laboratory of Sports Medicine, Aristotle University of Thessaloniki, Thessaloniki 57001, Greece
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Kao J, Reid N, Hubbard RE, Homes R, Hanjani LS, Pearson E, Logan B, King S, Fox S, Gordon EH. Frailty and solid-organ transplant candidates: a scoping review. BMC Geriatr 2022; 22:864. [PMCID: PMC9667636 DOI: 10.1186/s12877-022-03485-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
Abstract
Background
There is currently no consensus as to a standardized tool for frailty measurement in any patient population. In the solid-organ transplantation population, routinely identifying and quantifying frailty in potential transplant candidates would support patients and the multidisciplinary team to make well-informed, individualized, management decisions. The aim of this scoping review was to synthesise the literature regarding frailty measurement in solid-organ transplant (SOT) candidates.
Methods
A search of four databases (Cochrane, Pubmed, EMBASE and CINAHL) yielded 3124 studies. 101 studies (including heart, kidney, liver, and lung transplant candidate populations) met the inclusion criteria.
Results
We found that studies used a wide range of frailty tools (N = 22), including four ‘established’ frailty tools. The most commonly used tools were the Fried Frailty Phenotype and the Liver Frailty Index. Frailty prevalence estimates for this middle-aged, predominantly male, population varied between 2.7% and 100%. In the SOT candidate population, frailty was found to be associated with a range of adverse outcomes, with most evidence for increased mortality (including post-transplant and wait-list mortality), post-operative complications and prolonged hospitalisation. There is currently insufficient data to compare the predictive validity of frailty tools in the SOT population.
Conclusion
Overall, there is great variability in the approach to frailty measurement in this population. Preferably, a validated frailty measurement tool would be incorporated into SOT eligibility assessments internationally with a view to facilitating comparisons between patient sub-groups and national and international transplant services with the ultimate goal of improved patient care.
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Burfeind KG, Zarnegarnia Y, Tekkali P, O’Glasser AY, Quinn JF, Schenning KJ. Potentially Inappropriate Medication Administration Is Associated With Adverse Postoperative Outcomes in Older Surgical Patients: A Retrospective Cohort Study. Anesth Analg 2022; 135:1048-1056. [PMID: 35986676 PMCID: PMC9588532 DOI: 10.1213/ane.0000000000006185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The American Geriatrics Society (AGS) Beers Criteria is an explicit list of potentially inappropriate medications (PIMs) best avoided in adults ≥65 years of age. Cognitively impaired and frail surgical patients often experience poor outcomes after surgery, but the impacts of PIMs on these patients are unclear. Our objective was to assess whether perioperative PIM administration was associated with poor outcomes in geriatric surgical patients. We then evaluated the association between PIM administration and postoperative outcomes in subgroups of patients who were frail or cognitively impaired. METHODS We performed a retrospective cohort study of patients ≥65 years of age who underwent elective inpatient surgery at a large academic medical center from February 2018 to January 2020. Edmonton Frail Scale and Mini-Cog screening tools were administered to all patients at their preoperative clinic visit. A Mini-Cog score of 0 to 2 was considered cognitive impairment, and frailty was defined by an Edmonton Frail Scale score of ≥8. Patients were divided into 2 groups depending on whether they received at least 1 PIM (PIM+), based on the 2019 AGS Beers Criteria, in the perioperative period or none (PIM-). We assessed the association of preoperative frailty, cognitive impairment, and perioperative PIM administration with the length of hospital stay and discharge disposition using multiple regression analyses adjusted for age, sex, ASA physical status, and intensive care unit (ICU) admission. RESULTS Of the 1627 included patients (mean age, 73.7 years), 69.3% (n = 1128) received at least 1 PIM. A total of 12.7% of patients were frail, and 11.1% of patients were cognitively impaired; 64% of the frail patients and 58% of the cognitively impaired patients received at least 1 PIM. Perioperative PIM administration was associated with longer hospital stay after surgery (PIM-, 3.56 ± 5.2 vs PIM+, 4.93 ± 5.66 days; P < .001; 95% confidence interval [CI], 0.360-0.546). Frail patients who received PIMs had an average length of stay (LOS) that was nearly 2 days longer than frail patients who did not receive PIMs (PIM-, 4.48 ± 5.04 vs PIM+, 6.33 ± 5.89 days; P = .02). Multiple regression analysis revealed no significant association between PIM administration and proportion of patients discharged to a care facility (PIM+, 26.3% vs PIM-, 28.7%; P = .87; 95% CI, -0.046 to 0.054). CONCLUSIONS Perioperative PIM administration was common in older surgical patients, including cognitively impaired and frail patients. PIM administration was associated with an increased hospital LOS, particularly in frail patients. There was no association found between PIM administration and discharge disposition.
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Affiliation(s)
- Kevin G. Burfeind
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Yalda Zarnegarnia
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Praveen Tekkali
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Avital Y. O’Glasser
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
- Department of Medicine, Division of Hospital Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Joseph F. Quinn
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Katie J. Schenning
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
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Goffaux A, Delorme A, Dahlqvist G, Lanthier N. Improving the prognosis before and after liver transplantation: Is muscle a game changer? World J Gastroenterol 2022; 28:5807-5817. [PMID: 36353207 PMCID: PMC9639652 DOI: 10.3748/wjg.v28.i40.5807] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/30/2022] [Accepted: 10/11/2022] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) is currently the only curative treatment option for selected patients with end stage liver disease or hepatocellular carcinoma. Improving waiting list-mortality, post-transplant morbidity and mortality and refining the selection of the patients remain our current central objectives. In this field, different concepts dealing with nutrition and the muscle such as sarcopenia, malnutrition, frailty or myosteatosis have emerged as possible game changers. For more than a decade, many prospective studies have demonstrated that sarcopenia and frailty are major predictive factors of mortality in the waiting list but also after LT. Malnutrition is also a well-known risk factor for morbidity and mor-tality. Muscle composition is a newer concept giving insight on muscle quality which has also been shown to be linked to poorer outcomes. Each of these terms has a precise definition as well as pathophysiological mechanisms. The bi-directional liver-muscle axis makes sense in this situation. Defining the best, easy to use in clinical practice tools to assess muscle quality, quantity, and function in this specific population and developing quality prospective studies to identify interventional strategies that could improve these parameters as well as evaluate the effect on mortality are among the important challenges of today.
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Affiliation(s)
- Alexis Goffaux
- Laboratory of Hepato-Gastroenterology, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels 1200, Belgium
- Service d’Hépato-Gastroentérologie, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels 1200, Belgium
| | - Alicia Delorme
- Service d’Hépato-Gastroentérologie, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels 1200, Belgium
| | - Géraldine Dahlqvist
- Service d’Hépato-Gastroentérologie, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels 1200, Belgium
| | - Nicolas Lanthier
- Laboratory of Hepato-Gastroenterology, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels 1200, Belgium
- Service d’Hépato-Gastroentérologie, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels 1200, Belgium
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Haj Ali S, Abu Sneineh A, Hasweh R. Nutritional assessment in patients with liver cirrhosis. World J Hepatol 2022; 14:1694-1703. [PMID: 36185724 PMCID: PMC9521456 DOI: 10.4254/wjh.v14.i9.1694] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/09/2022] [Accepted: 09/09/2022] [Indexed: 02/06/2023] Open
Abstract
Malnutrition is a liver cirrhosis complication affecting more than 20%-50% of patients. Although the term can refer to either nutrient deficiency or excess, it usually relates to undernutrition in cirrhosis settings. Frailty is defined as limited physical function due to muscle weakness, whereas sarcopenia is defined as muscle mass loss and an advanced malnutrition stage. The pathogenesis of malnutrition in liver cirrhosis is multifactorial, including decreased oral intake, maldigestion/malabsorption, physical inactivity, hyperammonemia, hypermetabolism, altered macronutrient metabolism and gut microbiome dysbiosis. Patients with chronic liver disease with a Body Mass Index of < 18.5 kg/m2 and/or decompensated cirrhosis or Child-Pugh class C are at the highest risk of malnutrition. For patients at risk of malnutrition, a detailed nutritional assessment is required, typically including a history and physical examination, laboratory testing, global assessment tools and body composition testing. The latter can be done using anthropometry, cross-sectional imaging including computed tomography or magnetic resonance, bioelectrical impedance analysis and dual-energy X-ray absorptiometry. A multidisciplinary team should screen for and treat malnutrition in patients with cirrhosis. Malnutrition and sarcopenia are associated with an increased risk of complications and a poor prognosis in patients with liver cirrhosis; thus, it is critical to diagnose these conditions early and initiate the appropriate nutritional therapy. In this review, we describe the prevalence and pathogenesis of malnutrition in liver cirrhosis patients and discuss the best diagnostic approach to nutritional assessment for them.
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Affiliation(s)
- Sara Haj Ali
- Department of Internal Medicine, Faculty of Medicine, Al-Balqa Applied University, Salt 19117, Jordan
| | - Awni Abu Sneineh
- Department of Gastroenterology and Hepatology, University of Jordan, Faculty of Medicine, Amman 11942, Jordan
| | - Reem Hasweh
- Department of Internal Medicine, Faculty of Medicine, Al-Balqa Applied University, Salt 19117, Jordan
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Updated S2k Clinical Practice Guideline on Non-alcoholic Fatty Liver Disease (NAFLD) issued by the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - April 2022 - AWMF Registration No.: 021-025. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e733-e801. [PMID: 36100201 DOI: 10.1055/a-1880-2388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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Roeb E, Canbay A, Bantel H, Bojunga J, de Laffolie J, Demir M, Denzer UW, Geier A, Hofmann WP, Hudert C, Karlas T, Krawczyk M, Longerich T, Luedde T, Roden M, Schattenberg J, Sterneck M, Tannapfel A, Lorenz P, Tacke F. Aktualisierte S2k-Leitlinie nicht-alkoholische Fettlebererkrankung der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – April 2022 – AWMF-Registernummer: 021–025. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:1346-1421. [PMID: 36100202 DOI: 10.1055/a-1880-2283] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- E Roeb
- Gastroenterologie, Medizinische Klinik II, Universitätsklinikum Gießen und Marburg, Gießen, Deutschland
| | - A Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - H Bantel
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - J Bojunga
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin., Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - J de Laffolie
- Allgemeinpädiatrie und Neonatologie, Zentrum für Kinderheilkunde und Jugendmedizin, Universitätsklinikum Gießen und Marburg, Gießen, Deutschland
| | - M Demir
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum und Campus Charité Mitte, Berlin, Deutschland
| | - U W Denzer
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Marburg, Deutschland
| | - A Geier
- Medizinische Klinik und Poliklinik II, Schwerpunkt Hepatologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - W P Hofmann
- Gastroenterologie am Bayerischen Platz - Medizinisches Versorgungszentrum, Berlin, Deutschland
| | - C Hudert
- Klinik für Pädiatrie m. S. Gastroenterologie, Nephrologie und Stoffwechselmedizin, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - T Karlas
- Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - M Krawczyk
- Klinik für Innere Medizin II, Gastroent., Hepat., Endokrin., Diabet., Ern.med., Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - T Longerich
- Pathologisches Institut, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - T Luedde
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - M Roden
- Klinik für Endokrinologie und Diabetologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - J Schattenberg
- I. Medizinische Klinik und Poliklinik, Universitätsmedizin Mainz, Mainz, Deutschland
| | - M Sterneck
- Klinik für Hepatobiliäre Chirurgie und Transplantationschirurgie, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - A Tannapfel
- Institut für Pathologie, Ruhr-Universität Bochum, Bochum, Deutschland
| | - P Lorenz
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - F Tacke
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum und Campus Charité Mitte, Berlin, Deutschland
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48
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Garcia-Saenz-de-Sicilia M, Al-Obaid L, Hughes DL, Duarte-Rojo A. Mastering Core Recommendations during HEPAtology ROUNDS in Patients with Advanced Chronic Liver Disease. Semin Liver Dis 2022; 42:341-361. [PMID: 35764316 DOI: 10.1055/a-1886-5909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Efficient and thorough care of hospitalized patients with advanced chronic liver disease is of utter importance to improve outcomes and optimize quality of life. This requires understanding current evidence and best practices. To facilitate focus on up-to-date knowledge and a practical approach, we have created the HEPA-ROUNDS mnemonic while outlining a practical review of the literature with critical appraisal for the busy clinician. The HEPA-ROUNDS mnemonic provides a structured approach that incorporates critical concepts in terms of prevention, management, and prognostication of the most common complications frequently encountered in patients with advanced chronic liver disease. In addition, implementing the HEPA-ROUNDS mnemonic can facilitate education for trainees and staff caring for patients with advanced chronic liver disease.
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Affiliation(s)
| | - Lolwa Al-Obaid
- Division of Gastroenterology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Dempsey L Hughes
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrés Duarte-Rojo
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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49
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Lin FP, Bloomer PM, Grubbs RK, Rockette-Wagner B, Tevar AD, Dunn MA, Duarte-Rojo A. Low Daily Step Count Is Associated With a High Risk of Hospital Admission and Death in Community-Dwelling Patients With Cirrhosis. Clin Gastroenterol Hepatol 2022; 20:1813-1820.e2. [PMID: 35331941 PMCID: PMC10099369 DOI: 10.1016/j.cgh.2022.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/21/2022] [Accepted: 03/14/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Daily step count measures cardiorespiratory fitness and has been associated with clinical outcomes. However, its utility in patients with cirrhosis remains largely unexplored. We aimed to investigate the association between step count, frailty metrics, and clinical outcomes in cirrhosis. METHODS All participants underwent frailty evaluation with the liver frailty index, 6-minute walk test, and gait speed test. To monitor step count, participants were given a personal activity tracker (PAT). A subset also was invited to use Exercise and Liver FITness (EL-FIT). Daily step counts from the first week of PAT use and frailty metrics were investigated as predictors of hospital admission and mortality. RESULTS There were 116 patients included (age, 56 ± 11 y; male, 55%; body mass index, 31 ± 7; model for end-stage liver disease-sodium, 15 ± 7). The main etiologies of cirrhosis were alcohol-related (33%) and nonalcoholic steatohepatitis (30%). Monitoring for the week was accomplished in 80% of participants given both PAT+EL-FIT vs 62% in those with PAT only (P = .04). During follow-up evaluation, hospital admission was observed in 55% and death in 15%. Kaplan-Meir curves showed increased readmission and deaths among patients performing in the lowest quartile (ie, <1200 steps/d). When adjusted by model for end-stage liver disease-sodium and EL-FIT use, the lowest quartile was associated with hospital admission and death (hazard ratio, HR [95% confidence interval], 1.90 [1.09-3.30] and 3.46 [1.23-9.68], respectively), along with the 6-minute walk test (HR, 0.63 [0.47-0.83] and 0.66 [0.44-0.99] per 100 m, respectively) and gait speed test (HR, 0.29 [0.11-0.72] and 0.21 [0.05-0.84], respectively). CONCLUSIONS Daily step count predicted hospital admission and mortality rates in patients with cirrhosis, similar to the current standard frailty metrics. Incorporation of a physical training-dedicated smartphone application was associated with increased PAT use and step reporting.
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Affiliation(s)
| | - Pamela M Bloomer
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rachel K Grubbs
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Bonny Rockette-Wagner
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amit D Tevar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael A Dunn
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Andres Duarte-Rojo
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania.
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50
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Weil-Verhoeven D, Di Martino V, Stirnimann G, Cervoni JP, Nguyen-Khac E, Thévenot T. Alfapump ® implantable device in management of refractory ascites: An update. World J Hepatol 2022; 14:1344-1356. [PMID: 36158913 PMCID: PMC9376776 DOI: 10.4254/wjh.v14.i7.1344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/30/2022] [Accepted: 06/27/2022] [Indexed: 02/06/2023] Open
Abstract
Refractory ascites (RA) is a frequent and life-threatening complication of cirrhosis. In selected patients with RA, transjugular intrahepatic portosystemic shunt (TIPS) placement and liver transplantation (LT) are currently considered the best therapeutic alternatives to repeated large volume paracentesis. In patients with a contraindication to TIPS or LT, the alfapump® system (Sequana Medical, Ghent, Belgium) has been developed to reduce the need for iterative paracentesis, and consequently to improve the quality of life and nutritional status. We report here recent data on technical progress made since the first implantation, the efficacy and tolerance of the device, the position of the pump in the therapeutic arsenal for refractory ascites, and the grey areas that remain to be clarified regarding the optimal selection of patients who are potential candidates for this treatment.
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Affiliation(s)
- Delphine Weil-Verhoeven
- Service d’Hépatologie Et Soins Intensifs Digestifs, CHRU Jean Minjoz, Besançon 25030, France
- EA 4266 EPILAB, Université de Bourgogne Franche-Comté, Besançon 25030, France
| | - Vincent Di Martino
- Service d’Hépatologie Et Soins Intensifs Digestifs, CHRU Jean Minjoz, Besançon 25030, France
- EA 4266 EPILAB, Université de Bourgogne Franche-Comté, Besançon 25030, France
| | - Guido Stirnimann
- Department of Visceral Surgery and Medicine, Inselspital University Hospital and University of Bern, Bern 3010, Switzerland
| | - Jean Paul Cervoni
- Service d’Hépatologie Et Soins Intensifs Digestifs, CHRU Jean Minjoz, Besançon 25030, France
| | - Eric Nguyen-Khac
- Service d’Hépato-Gastroentérologie, CHU Amiens-Picardie, Amiens 80080, France
| | - Thierry Thévenot
- Service d’Hépatologie Et Soins Intensifs Digestifs, CHRU Jean Minjoz, Besançon 25030, France
- EA 4266 EPILAB, Université de Bourgogne Franche-Comté, Besançon 25030, France
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