Review article: prognostic significance of body composition abnormalities in patients with cirrhosis

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effects of nocturnal snacks on body composition in patients with liver cirrhosis

BACKGROUND

Patients with liver cirrhosis are universally malnourished and the nocturnal snacks intervention is the currently recommended nutritional intervention for patients with liver cirrhosis. Body composition is an important indicator for the assessment of nutritional conditions. We investigated the effects of nocturnal snacks (200 kcal/day) for 3 months on body composition in patients with liver cirrhosis.

AIM

To investigate the effect of nocturnal snacks on body composition in patients with cirrhosis.

METHODS

Seventy patients with liver cirrhosis and 30 healthy controls were enrolled, and differences in body composition were detected using InBody 720, a body composition analyzer. The patients were further randomized into a normal diet group (three meals a day) and nocturnal snacks group (three meals a day + nocturnal snacks). The effect of nocturnal snacks on the body composition of patients with cirrhosis was assessed after 3 months of intervention.

RESULTS

Body fat mass (BFM), skeletal muscle mass (SMM), fat free mass, visceral fat area (VFA), and body cell mass (BCM) were significantly lower in the liver cirrhosis patients than in the healthy controls. After 3 months’ intervention, BFM, VFA and BCM were significantly higher in the nocturnal snacks group than in the normal diet group, with no significant differences in total caloric intake and daily activity. However, there was no significant difference in SMM between the nocturnal snacks and normal diet groups.

CONCLUSION

Long-term nocturnal snacks may improve body composition indices such as BFM, VFA and BCM in patients with cirrhosis. However, the improvement was minor for SMM.

Hepatic immune regulation and sex disparities

Chronic liver disease is a major cause of morbidity and mortality worldwide. Epidemiology, clinical phenotype and response to therapies for gastrointestinal and liver diseases are commonly different between women and men due to sex-specific hormonal, genetic and immune-related factors. The hepatic immune system has unique regulatory functions that promote the induction of intrahepatic tolerance, which is key for maintaining liver health and homeostasis. In liver diseases, hepatic immune alterations are increasingly recognized as a main cofactor responsible for the development and progression of chronic liver injury and fibrosis. In this Review, we discuss the basic mechanisms of sex disparity in hepatic immune regulation and how these mechanisms influence and modify the development of autoimmune liver diseases, genetic liver diseases, portal hypertension and inflammation in chronic liver disease. Alterations in gut microbiota and their crosstalk with the hepatic immune system might affect the progression of liver disease in a sex-specific manner, creating potential opportunities for novel diagnostic and therapeutic approaches to be evaluated in clinical trials. Finally, we identify and propose areas for future basic, translational and clinical research that will advance our understanding of sex disparities in hepatic immunity and liver disease.

Impact of sarcopenia on variceal rebleeding in patients after endoscopic therapy: a multicenter retrospective cohort study based on propensity score matching

BACKGROUND

Sarcopenia is a common complication of liver cirrhosis and can be used for predicting dismal prognostic outcomes. This study aimed to evaluate the role of sarcopenia in rebleeding and mortality of liver cirrhosis patients after endoscopic therapy.

METHODS

The liver cirrhosis patients who received endoscopic treatment were enrolled. Propensity score matching (PSM) was used to overcome selection bias. Two-year rebleeding episodes and mortality after endoscopic therapy were recorded.

RESULTS

A total of 109 (32.4%) sarcopenia patients were reported. Before PSM, the frequency of rebleeding was significantly higher in the sarcopenia group relative to the non-sarcopenia group (41.3% vs. 15.9%, p < 0.001). Moreover, the multivariable analysis revealed that sarcopenia (p < 0.001, HR:2.596, 95% CI 1.591-4.237) was independently associated with a 2-year rebleeding episode. After PSM, the sarcopenia group exhibited an increased rebleeding rate as compared with non-sarcopenia group (44.4% vs. 15.3%, p < 0.001). According to multivariable analysis, sarcopenia (p < 0.001, HR:3.490, 95% CI 1.756-6.938) was identified as a significant predictor for 2-year rebleeding.

CONCLUSION

Sarcopenia was significantly associated with a high 2-year rebleeding rate in liver cirrhosis patients after endoscopic treatment. Therefore, the precise evaluation of a patient's nutritional status, including sarcopenia becomes mandatory before endoscopic treatment.

The relationship between imaging-based body composition abnormalities and long-term mortality in patients with liver cirrhosis

BACKGROUND

Emerging evidence on cirrhosis suggests a close correlation between abnormality in body composition characteristics and poor prognosis. This study aimed to evaluate the impact of dynamic changes in body composition on the prognostic outcomes in patients with cirrhosis.

METHODS

This retrospective analysis included 158 patients diagnosed as cirrhosis from January 2018 to August 2023. Skeletal muscle mass, muscle quality, visceral and subcutaneous adiposity were evaluated using computed tomography (CT) imaging at the third lumbar vertebra level. Competing risk model was performed four different body composition status (i.e., normal, only sarcopenia, only myosteatosis, and combined status) for liver-related mortality. We also explored the relationship between the dynamic change in body composition and long-term prognosis by applying Gray's test.

RESULTS

Of the 158 cirrhotic patients (mean [SD] age, 57.1 [12.6] years), sarcopenia was present in 85 (60.1 %) patients, while 22 (13.9 %) patients had sarcopenic obesity and 68 (43.0 %) had myosteatosis. Patients solely diagnosed with sarcopenia exhibited a higher mortality rate compared to those with normal body composition (Gray's test, P=0.006), while patients solely diagnosed with myosteatosis or with a combination of sarcopenia and myosteatosis did not reach statistical significance (Gray's test, P=0.076; P=0.140). Multivariable analysis also revealed that VSR (HR=1.10 [1.01∼1.20]; P=0.028), sarcopenia (HR=2.73 [1.20∼6.22], P=0.017) and myosteatosis (HR=2.39 [1.10∼5.18], P=0.028) were significant independent predictors of liver-related deaths. Otherwise, patients exhibiting aggravating body composition during follow-up period were associated with a significantly higher mortality risk compared to those with normal or remission body composition status (HR=7.63 [1.12∼51.14]; P=0.036).

CONCLUSION

Progressive alterations in body composition status appears to be associated with liver-related mortality in individuals with liver cirrhosis. Focusing on the management of skeletal muscle, along with visceral and subcutaneous adiposity, may contribute to improving the prognosis of cirrhotic patients.

A sex-oriented analysis concerning skeletal muscle quantity and quality and associations to quality of life in hospitalized patients with cirrhosis

BACKGROUND

There is a paucity of data regarding sex-oriented analyses of connection between muscle quantity and quality and health-related quality of life (HRQoL), taking into account the pathophysiological differences of sarcopenia/myosteatosis in males versus females. We sought to investigate the associations between skeletal muscle index (SMI)-defined sarcopenia and intramuscular adipose tissue content (IMAC)-defined myosteatosis and EuroQol-5D (EQ-5D)-defined HRQoL in patients with decompensated cirrhosis concerning sex disparities.

METHODS

Totally, 382 patients were enrolled. The relationship between SMI/IMAC and HRQoL was evaluated with restricted cubic spline and Pearson correlation analyses. Furthermore, association between SMI or sarcopenia and EQ-5D utility index was determined by multiple linear regression, adjusted for age, BMI and concurrent disease severity.

RESULTS

The study population comprised evenly distributed male and female patients (190: 192), mean age 61.9 years. The prevalence of sarcopenia (40.5 versus 9.9%, P < 0.001) and SMI (48.8 versus 42.2 cm2/m2, P < 0.001) were significantly higher in males relative to females, with comparable myosteatosis prevalence (15.3 versus 16.7%, P = 0.708). Self-care, usual activities and pain within EQ-5D scale were more prevalent in the sarcopenia compared with non-sarcopenia groups across entire population and stratified by sex. The SMI values exhibited a significantly linear correlation with EQ-5D utility index in male but not female patients (P for non-linearity = 0.281). In multiple analysis, SMI or the presence of sarcopenia was both significantly associated with EQ-5D utility index. Subgroup analyses unveiled no discernible interactions between sarcopenia and EQ-5D utility index.

CONCLUSIONS

Muscle quantity measured by SMI was associated with declined HRQoL in males rather than females, whereas no associations were found regarding muscle quality measured by IMAC in both sexes. It is tempting to manage sarcopenia by increasing SMI levels as high as possible in hopes of achieving better health consequence. Our findings represent the importance of connecting CT-demarcated body composition abnormalities to meaningful patient-centered outcomes. Future targeted studies with sizable multi-center populations are warranted to clarify this causality, and in consequence develop optimized intervention against sarcopenia/myosteatosis or key determinants concerning impaired HRQoL.

Skeletal muscle mass increases after viral eradication with direct-acting antivirals in patients with chronic hepatitis C: A longitudinal study

BACKGROUND

Results of studies evaluating the effect of viral eradication following direct-acting antiviral (DDA) therapy on skeletal muscle mass of patients with chronic hepatitis C (CHC) are scarce.

AIM

To assess the components of sarcopenia (low muscle mass, low muscle strength and low physical performance) in a cohort of CHC individuals before and after DAA therapy.

METHODS

We performed a longitudinal study of patients with CHC who underwent body composition assessment before (T0), and at 12 (T1) and 48 (T2) weeks after DDA therapy. Bioelectrical Impedance Analysis was used to assess skeletal mass muscle (SM) and phase angle (PhA). SM index (SMI) was calculated by dividing the SM by squared height. Muscle function was evaluated by hand grip strength (HGS) and timed up-and-go (TUG) test. Mixed-effects linear regression models were fitted to SMI, HGS and physical performance and were used to test the effect of HCV eradication by DAA.

RESULTS

62 outpatients (mean age, 58.6 ± 10.8 years; 58% with compensated cirrhosis) were included. Significant decreases in liver fibrosis markers and an increase of 0.20 and 0.22 kg/m2 in the SMI were observed at T1 and T2. Following DAA therapy, an increase of one unit of PhA was associated with a reduction of 0.38 min in TUG.

CONCLUSION

HCV eradication with DAA therapy was associated with a dynamic reduction of non-invasive markers of liver fibrosis and increased muscle mass in 62 patients with CHC who had an undetectable HCV load at 12 weeks after completion of antiviral treatment.

Association of the fat mass index with hepatic steatosis and fibrosis: evidence from NHANES 2017-2018

Limited population-based studies discuss the association between fat mass index (FMI) and the risk of liver diseases. This investigation utilized data from the National Health and Nutrition Examination Survey (NHANES) to examine the linkage between the FMI and liver conditions, specifically steatosis and fibrosis. The study leveraged data from NHANES's 2017-2018 cross-sectional study, employing an oversampling technique to deal with sample imbalance. Hepatic steatosis and fibrosis were identified by vibration-controlled transient elastography. Receiver operating curve was used to assess the relationship of anthropometric indicators, e.g., the FMI, body mass index (BMI), weight-adjusted-waist index (WWI), percentage of body fat (BF%), waist-to-hip ratio (WHR), and appendicular skeletal muscle index (ASMI), with hepatic steatosis and fibrosis. In this study, which included 2260 participants, multivariate logistic regression models, stratified analyses, restricted cubic spline (RCS), and sharp regression discontinuity analyses were utilized. The results indicated that the WHR and the FMI achieved the highest area under the curve for identifying hepatic steatosis and fibrosis, respectively (0.720 and 0.726). Notably, the FMI presented the highest adjusted odds ratio for both hepatic steatosis (6.40 [4.91-8.38], p = 2.34e-42) and fibrosis (6.06 [5.00, 7.37], p = 5.88e-74). Additionally, potential interaction effects were observed between the FMI and variables such as the family income-to-poverty ratio, smoking status, and hypertension, all of which correlated with the presence of liver fibrosis (p for interaction < 0.05). The RCS models further confirmed a significant positive correlation of the FMI with the controlled attenuation parameter and liver stiffness measurements. Overall, the findings underscore the strong link between the FMI and liver conditions, proposing the FMI as a potential straightforward marker for identifying liver diseases.

Influence of subcutaneous adipose tissue index on prognosis in cirrhotic patients following endoscopic therapy: a retrospective cohort study

BACKGROUND

The relation of adipose tissue depletion with prognostic outcome of variceal bleeding among cirrhotic patients is still inconclusive. The present work explored whether adipose tissue, which was measured based on computed tomography (CT), was valuable for analyzing rebleeding and mortality among patients with variceal bleeding who had undergone endoscopic therapy.

METHODS

The study encompassed cirrhotic patients who underwent endoscopic therapy to prevent variceal rebleeding between January 2016 and October 2022. The L3-level CT images were obtained. Besides, impacts of subcutaneous adipose tissue index (SATI), visceral adipose tissue index (VATI), as well as total adipose tissue index (TATI) on rebleeding and mortality among cirrhotic patients following endoscopic therapy were examined.

RESULTS

In this work, our median follow-up period was 31 months. Among those adipose tissue indexes, only SATI exhibited an independent relation to higher rebleeding (HR 0.981, 95% CI, 0.971-0.991, p < 0.001) and mortality (HR 0.965, 95% CI, 0.944-0.986, p = 0.001) risks. Upon multivariate Cox regression, low SATI (male < 30.15 cm2/m2, female < 39.82 cm2/m2) was independently linked to higher rebleeding risk (HR 2.511, 95% CI, 1.604-3.932, p < 0.001) and increased mortality risk (HR 3.422, 95% CI, 1.489-7.864, p = 0.004) after adjusting for other predictors. Furthermore, subgroups were created based on using nonselective β-blockers (NSBBs), demonstrating that quantitatively assessing SATI exerts a vital role in evaluating rebleeding incidence in patients with or without NSBB therapy.

CONCLUSION

This study underscores the potential of quantifying SATI as a means for achieving a more accurate risk classification for individual patients and identifying patients that can gain more benefits from nutritional intervention.

Reduced muscle strength is closely linked to computed tomography-defined myosteatosis among inpatients with cirrhosis

BACKGROUND

Myosteatosis indicates pathological fat infiltration in muscles and is regarded as a distinct disease from sarcopenia. This muscular condition exhibits a link to muscle fiber disarrangement coinciding with disrupted muscle contractility and weakened mechanical action, mirrored as decreased muscle quality. However, the relationship between handgrip strength (HGS) and computed tomography-defined myosteatosis among cirrhosis is unclear. We aimed to investigate the association between HGS and myosteatosis and determine gender-specific cutoffs regarding HGS to identify myosteatotic subjects.

METHODS

We prospectively recruited 221 cirrhotic patients. The presence of myosteatosis was determined according to intramuscular adipose tissue content. The relationship between HGS and myosteatosis was evaluated according to Spearman correlation coefficient, area under the ROC curve, and multivariate logistic regression analysis. Moreover, a model based on the classification and regression tree method was generated.

RESULTS

Our results showed that HGS exhibits modestly negative correlation with intramuscular adipose tissue content in the entire cohort (rs = -0.269, P < .001) and across diverse subgroups precluding extremely deteriorating conditions. After controlling for multiple clinical features and biochemical parameters, HGS (odds ratio = 0.921, P = .010) was independently associated with myosteatosis in addition to age and body mass index. On applying the Japan Society of Hepatology-recommended cutoffs, an area under the ROC curve of HGS was 0.627 with a sensitivity of 77.4% and a specificity of 47.9%. The decision tree including body mass index and low HGS correctly classified ~85% of the cases in development and validation sets.

CONCLUSIONS

HGS was in close relation to myosteatosis among inpatients with cirrhosis.

Transjugular Intrahepatic Portosystemic Shunt Placement: Effects on Nutritional Status in Cirrhotic Patients

Malnutrition is a tangible complication of cirrhosis with portal hypertension with a prevalence of up to 50%. In particular, sarcopenia and myosteatosis, defined as the alteration in muscle quantity and quality, have a negative impact on the main complications of liver disease and are associated with higher mortality in patients with cirrhosis. Recently, alterations in adipose tissue have also been described in cirrhotic patients and they seem to influence the course of liver disease. Several pieces of evidence indicate that a transjugular intrahepatic portosystemic shunt (TIPS), placed for the treatment of refractory portal hypertension, can lead to a modification of body composition consisting in the improvement of the skeletal muscle index, myosteatosis, and an increase in subcutaneous fat. These modifications of the nutritional status, even more pronounced in sarcopenic patients before TIPS, have been associated with an amelioration of cognitive impairment after TIPS as well as with an increase in the survival rate. The aim of this paper is to provide an overview of the effects of TIPS placement on nutritional status in cirrhosis focusing on its pathophysiological mechanisms and its relationship with liver-related outcomes.

Myosteatosis independently predicts transplant-free survival in patients with primary sclerosing cholangitis

BACKGROUND

Primary Sclerosing Cholangitis (PSC) is a progressive cholestatic liver disease with liver transplantation (LT) as the only curative therapy. Some regions use body-weight-loss as standard-exception criteria for organ allocation but data on the impact of body composition on survival of patients with PSC is scarce.

METHODS

Abdominal MRI of PSC patients were quantitatively analyzed for intramuscular fat fraction (IMFF) as surrogate of myosteatosis. Clinical and laboratory data were retrieved from patient records. Primary outcome was transplant-free survival (TFS).

RESULTS

116 PSC patients were included. Median age was 38 (18-71) years with 74 (64%) male patients. 15 (13%) patients had significant weigh loss. IMFF was significantly associated with survival. Multivariate regression analysis showed IMFF ≥ 15% as independent predictor for TFS (p = 0.032, HR 3.215 CI 1.104-9.366), but not significant weight loss (p = 0.618).

CONCLUSION

IMFF is independently associated with TFS in patients with PSC and may identify patients with more urgent need for LT. NCT03584204.

CT Radiomics Features of Abdominal Adipose and Muscle Tissues Can Predict the Postoperative Early Recurrence of Hepatocellular Carcinoma

RATIONALE AND OBJECTIVES

To investigate the potential of computed tomography radiomics features extracted from abdominal adipose and muscle in predicting early recurrence (ER) of hepatocellular carcinoma (HCC) after surgery.

MATERIALS AND METHODS

This retrospective study enrolled 252 patients with HCC who underwent curative resection from two independent institutions. In the training cohort of 178 patients from institution A, radiomics signatures extracted from abdominal visceral adipose, subcutaneous adipose, and muscle were applied to establish the radiomics score using the least absolute shrinkage and selection operator regression. Using multivariable Cox regression analysis, two models were developed: one incorporated preoperative variables, and the other incorporated both pre- and postoperative variables. The external validation of the two models was conducted at institution B with 74 patients.

RESULTS

The preoperative model incorporated tumor size, alpha-fetoprotein, body mass index, and radiomics score, whereas the postoperative model additionally integrated Edmondson-Steiner grade on the basis of the aforementioned parameters. In both cohorts, both models demonstrated superior performance to traditional staging systems and corresponding clinical models (P < 0.01), with time-dependent area under the curve exceeding 0.81 and concordance indices exceeding 0.72. Furthermore, the two models exhibited lower prediction errors (integrated Brier score < 0.19), well-calibrated calibration curves, and greater net clinical benefits. Finally, the two radiomics-based models facilitated risk stratification by accurately distinguishing the high-, intermediate-, and low-risk groups for ER (P < 0.01).

CONCLUSION

Statistical models integrating the radiomics data of abdominal adipose and muscle can provide accurate and reliable predictions of postoperative ER for patients with HCC.

Coexistence of muscle atrophy and high subcutaneous adipose tissue radiodensity predicts poor prognosis in hepatocellular carcinoma

Introduction

We aimed to assess the prognostic implications of muscle atrophy and high subcutaneous adipose tissue (SAT) radiodensity in patients with hepatocellular carcinoma (HCC).

Methods

In this retrospective study, muscle atrophy was assessed using the psoas muscle index (PMI) obtained from computed tomography. SAT radiodensity was evaluated based on radiodensity measurements. Survival and multivariate analyses were performed to identify factors associated with prognosis. The impact of muscle atrophy and high SAT radiodensity on prognosis was determined through survival analysis.

Results

A total of 201 patients (median age: 71 years; 76.6% male) with HCC were included. Liver cirrhosis was observed in 72.6% of patients, and the predominant Child-Pugh grade was A (77.1%). A total of 33.3% of patients exhibited muscle atrophy based on PMI values, whereas 12.9% had high SAT radiodensity. Kaplan-Meier survival analysis demonstrated that patients with muscle atrophy had significantly poorer prognosis than those without muscle atrophy. Patients with high SAT radiodensity had a significantly worse prognosis than those without it. Muscle atrophy, high SAT radiodensity, the Barcelona Clinic Liver Cancer class B, C, or D, and Child-Pugh score ≥ 6 were significantly associated with overall survival. Further classification of patients into four groups based on the presence or absence of muscle atrophy and high SAT radiodensity revealed that patients with both muscle atrophy and high SAT radiodensity had the poorest prognosis.

Conclusion

Muscle atrophy and high SAT radiodensity are significantly associated with poor prognosis in patients with HCC. Identifying this high-risk subgroup may facilitate the implementation of targeted interventions, including nutritional therapy and exercise, to potentially improve clinical outcomes.

The Presence of Myosteatosis Is Associated with Age, Severity of Liver Disease and Poor Outcome and May Represent a Prodromal Phase of Sarcopenia in Patients with Liver Cirrhosis

BACKGROUND/AIMS

Myosteatosis implies impaired muscle quality. The aim of the study was to investigate the association of myosteatosis with other muscle abnormalities and its role in the prognosis of liver cirrhosis (LC).

METHOD

Skeletal muscle index (SMI) and myosteatosis were measured by computed tomography. Myosteatosis was defined as muscle radiodensity and evaluated according to dry body mass index (BMI). Median values and interquartile range were used for continuous and count (percentage) for categorical variables.

RESULTS

A total of 197 consecutive patients were included (age 61 (IQR 52-68); 67% male; MELD score 11 (interquartile range 7.5-16)). Myosteatosis was identified in 73.6% and sarcopenia in 44.6% of patients. Myosteatosis was positively associated with age (p = 0.024) and Child-Pugh (p = 0.017) and inversely associated with SMI (p = 0.026). Patients with myosteatosis exhibited lower 360-day survival (log-rank p = 0.001) compared to those without it. MELD (p < 0.001) and myosteatosis (p = 0.048) emerged as negative prognostic factors of survival in multivariate model. Individuals combining low muscle strength and impaired muscle quality and quantity displayed more advanced LC, impaired muscle performance, lower BMI (p < 0.001 each) and a three times higher mortality rate compared to those with low muscle quality alone.

CONCLUSIONS

The presence of myosteatosis was associated with advanced age, low skeletal mass and more severe LC. Myosteatosis was associated with poor prognosis and may represent a prodromal phase of muscle degeneration before the development of sarcopenia.

Relationship between lipid profiles and reduced handgrip strength (dynapenia) in hospitalized patients with cirrhosis

BACKGROUND

Dynapenia embraces clinical significance and predictive value separated from skeletal muscle loss among cirrhosis. Moreover, alterations in lipid levels may impact muscle function. It has yet to elucidate the relationship between lipid profiles and muscle strength weakness. We sought to explore which lipid metabolism indicator could be useful to identify patients with dynapenia in daily practice.

METHODS

A retrospective observational cohort study enrolling 262 cirrhotic patients. Analysis of the receiver operating characteristic (ROC) curve was performed to determine the discriminatory cutoff for dynapenia. Multivariate logistic regression was conducted to assess the association between total cholesterol (TC) and dynapenia. Also, we established a model based on the classification and regression tree method.

RESULTS

ROC implicated a cutoff of TC ≤ 3.37 mmol/L to identify dynapenia. Patients with TC ≤ 3.37 mmol/L showed significantly lower handgrip strength (HGS; 20.0 vs. 24.7 kg, P  = 0.003), lower hemoglobin, lower platelet, lower white blood cell count, lower sodium and higher prothrombin-international normalized ratio. A positive correlation was found between TC and HGS values ( r  = 0.1860, P  = 0.003). TC remained a significant association with dynapenia after controlling for variables including age, sex, BMI, and the presence of ascites. The decision tree incorporating TC, BMI, and age had a sensitivity of 71.4%, specificity of 64.9%, and an area under ROC of 0.681.

CONCLUSION

TC ≤ 3.37 mmol/L was significantly associated with the presence of dynapenia. Assessing TC may be helpful for identifying dynapenic patients with cirrhosis in the health care or hospital setting.

2D shear wave elastography of the rectus femoris muscle in patients with cirrhosis: Feasibility and clinical findings. A pilot study

BACKGROUND AND AIMS

Frailty is frequent in cirrhosis and associated with skeletal muscle abnormalities and worse prognosis. 2D shear-wave elastography (2D-SWE) could mirror biomechanical properties of skeletal muscle reflecting muscle quality. However, there is no data on 2D-SWE on skeletal muscle stiffness assessment in cirrhosis and on frailty.

METHODS

Outpatients with cirrhosis were prospectively included in a single center. Skeletal muscle stiffness was studied at the rectus femoris by 2D-SWE. Ileo-psoas area and index (area/height²), and antero-posterior diameter of rectus femoris (RF) was measured on ultrasound.

RESULTS

We included 44 patients (24 male, age 59 [IQR 49-66]) with a median liver frailty index (LFI) of 3.7 (IQR 3.2-4.0). Measurement of RF muscle stiffness (RFMS) was feasible in all with high inter-measurement reproducibility. RFMS did not correlate with LFI, liver function and skeletal muscle diameters. Ileo-psoas index was lower in frail patients (1.7 vs 1.0 cm²/m², p = 0.024). RF antero-posterior diameter inversely correlated with LFI (r -0.578: p<0.001).

CONCLUSION

RFMS by 2D-SWE is feasible and reproducible in cirrhosis and is independent of liver function and LFI, and warrants further studies in this setting. RF antero-posterior diameter could be reported as an objective parameter mirroring sarcopenia and frailty.

Muscle abnormalities in patients with liver cirrhosis and its effect on muscle function

OBJECTIVES

The progression of chronic liver disease is associated with metabolic alterations that compromise the patient's body composition and physical function. Muscle wasting often occurs with pathologic fat accumulation in the muscle (myosteatosis). Unfavorable changes in body composition frequently arise in conjunction with a decrease in muscle strength. These conditions are associated with worse prognoses. The aim of this study was to explore the associations between computed tomography (CT)-derived measures of muscle mass and muscle radiodensity (myosteatosis) and its correlation with muscle strength in patients with advanced chronic liver disease.

METHODS

This cross-sectional study was conducted between July 2016 and July 2017. CT images at the third lumbar vertebra level (L3) were analyzed, and skeletal muscle index (SMI) and skeletal muscle radiodensity (SMD) were defined. Handgrip strength (HGS) was assessed by dynamometry. Correlations between CT-assessed body composition and HGS were tested. Multivariable linear regression was used to determine the factors associated with HGS.

RESULTS

We evaluated 118 patients with cirrhosis, of whom 64.4% were men. Of those evaluated, the mean age was 57.5 ± 8.5 y. Both SMI and SMD showed a positive correlation with muscle strength (r = 0.46 and 0.25, respectively); and age and Model for End-Stage Liver Disease (MELD)score showed the highest negative correlations (r = -0.37 and -0.34, respectively). In multivariable analyses, the presence of comorbidities (≥1), MELD score, and SMI were significantly associated with HGS.

CONCLUSIONS

Low muscle mass and clinical characteristics of disease severity may adversely affect muscle strength in patients with liver cirrhosis.

U-shaped relationship between subcutaneous adipose tissue index and mortality in liver cirrhosis

BACKGROUND

Subcutaneous and visceral adipose tissues are important body components, but their effects on the mortality in patients with liver cirrhosis remain controversial based on the current evidence.

METHODS

We retrospectively identified 372 eligible patients in whom subcutaneous adipose tissue index (SATI) and visceral adipose tissue index (VATI) could be measured by computed tomography images at the third lumbar vertebra. The association of SATI and VATI with the risk of death was evaluated on a continuous scale with restricted cubic spline curves based on Cox proportional hazards models. Cumulative probability of mortality was estimated by Nelson-Aalen cumulative risk curve analyses. Independent predictors of death were evaluated by competing risk analyses after adjusting for age, sex, and model for end-stage liver disease score.

RESULTS

Majority of patients were male (69.4%) with a mean age of 55.40 ± 10.68 years. SATI had a U-shaped association with mortality (P for non-linearity <0.001). Cutoff values of SATI were 19.7 and 51.8 cm² /m² at the points where hazard ratios were just <1.2. SATI was categorized as low (<19.7 cm² /m² ), moderate (19.7-51.8 cm² /m² ), and high (>51.8 cm² /m² ) level. There was no significant difference in the cumulative probability of mortality between low versus moderate SATI groups (Gray's test, P = 0.052) and high versus moderate SATI groups (Gray's test, P = 0.054). Competing risk analyses demonstrated that low SATI could increase the mortality compared with moderate SATI (subdistribution hazard ratio [sHR] = 1.66, 95% confidence interval [CI]: 0.992-2.78, P = 0.054) and was an independent predictor of death (sHR = 1.86, 95% CI: 1.059-3.28, P = 0.031). Competing risk analyses also demonstrated that high SATI could significantly increase the mortality compared with moderate SATI (sHR = 1.6, 95% CI: 1-2.54, P = 0.049), and was an independent predictor of death (sHR = 2.007, 95% CI: 1.195-3.37, P = 0.0085). VATI had an irregularly shaped association with mortality (P for non-linearity <0.001). Cutoff values of VATI were 9.8 and 40.2 cm² /m² at the points where hazard ratios were just <1.2. VATI was categorized as low (<9.8 cm² /m² ), moderate (9.8-40.2 cm² /m² ), and high (>40.2 cm² /m² ) level. There was no significant difference in the cumulative probability of mortality between low versus moderate VATI groups (Gray's test, P = 0.381) and high versus moderate VATI groups (Gray's test, P = 0.787). Competing risk analyses demonstrated that neither low (sHR = 1.27, 95% CI: 0.599-2.7, P = 0.53) nor high VATI (sHR = 0.848, 95% CI: 0.539-1.34, P = 0.48) was an independent predictor of death compared with moderate VATI.

CONCLUSIONS

Both excessive deficiency and accumulation of subcutaneous adipose tissues negatively influence the outcomes of cirrhotic patients.

Comparison of the GLIM criteria with specific screening tool for diagnosing malnutrition in hospitalized patients with cirrhosis: A descriptive cross-sectional study

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) has been built to diagnose malnutrition; however, its validity among patients with cirrhosis remains enigmatic. We aimed to investigate the prevalence of malnutrition according to GLIM criteria and compare the differences by using a specific screening tool.

METHODS

We conducted a descriptive cross-sectional study analyzing hospitalized patients. The Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) was chosen as the screening tool. Estimated prevalence was shown with and without the initial screening process. Diverse combinations of phenotypic and etiologic criteria and distinct body mass index (BMI) cutoffs were applied to detect frequency of malnourished patients with cirrhosis.

RESULTS

Overall, 363 patients were recruited (median age, 64 years; 51.2% female). The prevalence of malnutrition according to GLIM criteria with and without RFH-NPT screening was 33.3% and 36.4%, respectively. Low BMI and inflammation represented the most prevalent combination resulting in a malnutrition diagnosis (42.4%), followed by low BMI and reduced food intake (39.4%). By contrast, the least prevalence was found when combining reduced muscle mass with inflammation to diagnose malnutrition. Furthermore, the frequency of malnourished and well-nourished participants was not statistically different when using divergent BMI reference values across the study population.

CONCLUSIONS

GLIM criteria may serve a specific proxy to diagnose malnutrition, along with RFH-NPT screening. Relevant investigation is required to report on the applied combination of phenotypic/etiologic criteria, taking into consideration the marked impact of different models. More attempts are warranted to delineate the prognostic role of GLIM criteria in the context of cirrhosis.

Improvement of sarcopenia is beneficial for prognosis in cirrhotic patients after TIPS placement

BACKGROUND

The relationship between the improvement of sarcopenia and post-TIPS prognosis has not been fully investigated.

AIMS

To assess what level of sarcopenia improvement is required for potential benefits to post-TIPS prognosis.

METHODS

In this retrospective study, 109 cirrhotic patients with sarcopenia who underwent TIPS between February 2016 and January 2021 were included. The change in skeletal muscle index (SMI) at 6 months post-TIPS was assessed and the correlations of SMI improvement with clinical outcomes were analyzed.

RESULTS

During follow up, 59 (65.6%) patients reversed from sarcopenic to non-sarcopenic, and the cumulative mortality (8.5 % vs. 26.0%, log rank P = 0.013) and incidence of overt hepatic encephalopathy (OHE) (18.6% vs. 44.0%, log rank P = 0.004) in patients who reversed were significantly lower than who did not. SMI improvement rate was identified as an independent risk factor for mortality and OHE. In addition, the cumulative survival rate of patients with sarcopenia reversal or SMI improvement rate > 10.4% was significantly higher than that of patients with an SMI improvement rate ≤ 10.4% (92.5% vs. 58.6%, log rank P < 0.001).

CONCLUSION

Reversal of sarcopenia or significant SMI improvement by TIPS could reduce the risk of death and OHE.

High visceral adipose tissue area is independently associated with early allograft dysfunction in liver transplantation recipients: a propensity score analysis

OBJECTIVES

To evaluate the association between adipose tissue distribution and early allograft dysfunction (EAD) in liver transplantation (LT) recipients.

METHODS

A total of 175 patients who received LT from April 2015 to September 2020 were enrolled in this retrospective study. The areas of abdominal adipose tissue and skeletal muscle of all patients were measured based on the preoperative CT images. The appropriate statistical methods including the propensity score-matched (PSM) analysis were performed to identify the association between adipose tissue distribution and EAD.

RESULTS

Of 175 LT recipients, 55 patients (31.4%) finally developed EAD. The multivariate logistic analysis revealed that preoperative serum albumin (odds ratio (OR) 0.34, 95% confidence interval (CI) 0.17-0.70), platelet-lymphocyte ratio (OR 2.35, 95% CI 1.18-4.79), and visceral adipose tissue (VAT) area (OR 3.17, 95% CI 1.56-6.43) were independent associated with EAD. After PSM analysis, VAT area was still significantly associated with EAD (OR 3.95, 95% CI 1.16-13.51). In survival analysis, no significant difference was identified in one-year graft failure (log-rank: p = 0.487), and conversely result was identified in overall survival (OS) (log-rank: p = 0.012; hazard ratio (HR) 4.10, 95% CI 1.27-13.16).

CONCLUSIONS

LT recipients with high VAT area have higher risk for the occurrence of EAD, and high VAT area might have certain clinical value for predicting the poor OS of patients. For LT candidates with large amount of VAT, the clinicians can take clinical interventions by suggesting physical and nutritional treatments to improve outcomes after LT.

Which preoperative assessment modalities best identify patients who are suitable for enhanced recovery after liver transplantation? A systematic review of the literature and expert panel recommendations

BACKGROUND

To implement Enhanced Recovery After Surgery (ERAS) protocols for liver transplant (LT) candidates, it is essential to identify tools that can help risk stratify patients by their risk of early adverse post-LT outcomes.

OBJECTIVE

We aimed to identify pre-LT tools that assess functional capacity, frailty, and muscle mass that can best risk stratify patients by their risk of adverse post-LT outcomes.

METHODS

We first conducted a systematic review following PRISMA guidelines, expert panel review and recommendations using the GRADE approach (PROSPERO ID CRD42021237434). After confirming there are no studies evaluating assessment modalities for ERAS protocols for LT recipients specifically, the approach of the review focused on pre-LT modalities that identify LT recipients at higher risk of worse early post-LT outcomes (≤90 days), considering that this is particularly pertinent when evaluating candidates for ERAS.

RESULTS

Twenty-two studies were included in the review, encompassing three different types of pre-LT modalities: evaluation of physical function (including frailty and general physical scores like the Karnofsky Performance Status (KPS), assessment of cardiopulmonary capacity, and estimation of muscle mass and composition. The majority of studies evaluated frailty assessment and muscle mass. Most studies, except for liver frailty index (LFI), were retrospective and single-center. All assessment modalities could identify, in different grade, LT recipients with higher risk of early post-LT mortality, length of stay or postoperative complications.

CONCLUSIONS

We identified four pre-LT assessment tools that could be used to identify patients who are suitable for ERAS protocols: (1) KPS (quality of evidence moderate, grade of recommendation strong); (2) LFI (quality of evidence moderate, grade of recommendation strong); (3) abdominal muscle mass by CT (quality of evidence moderate, grade of recommendation strong); and (4) cardiopulmonary exercise testing (CPET) (quality of evidence moderate, grade of recommendation weak). We recommend that selection of the appropriate tool depends on the specific clinical setting and available resources to administer the tool, and that use of a tool be incorporated into the routine preoperative assessment when considering implementation of ERAS protocols for LT.

Association of myosteatosis with various body composition abnormalities and longer length of hospitalization in patients with decompensated cirrhosis

BACKGROUND

Myosteatosis is linked to dismal outcomes in the context of cirrhosis. However, the association of myosteatosis with various body composition abnormalities remains enigmatic. We aimed to clarify the determinants of myosteatosis and its relationship with other body composition profiles and length of hospitalization (LOH).

METHODS

We retrospectively analyzed the data of 473 consecutive patients with cirrhosis hospitalized for decompensation. Computed tomography-based segmentation of the cross-sectional area at the third lumbar vertebra was used to evaluate body composition abnormalities. The categories of myosteatosis were built according to our previously outcome-based cutoffs for each gender.

RESULTS

Totally, 83 patients (17.55%) were stratified as myosteatosis, of whom 85.54% had concomitant high visceral adiposity indicative of increased visceral adipose tissue index (VATI). The prevalence of sarcopenia showed no significant difference between the groups with and without myosteatosis. Multivariate analysis showed that advanced age [odds ratio (OR) = 1.097, p < 0.001], higher visceral to subcutaneous ratio of adipose tissue area (VSR; OR = 1.574, p = 0.032), and higher VATI (OR = 1.026, p < 0.001) are independently associated with myosteatosis. Correlation analyses revealed a positive relationship between intramuscular adipose tissue content (IMAC) and VATI (ρ = 0.48, p < 0.001), subcutaneous adipose tissue index (SATI) (ρ = 0.36, p < 0.001), and age (ρ = 0.36, p < 0.001). None of the skeletal muscle or adipose tissue indicators were significantly related to longer LOH.

CONCLUSION

Higher VSR, higher VATI, and advanced age are associated with myosteatosis among patients with cirrhosis at the decompensation phase. It is tempting to target divergent adipose tissue depots aimed at timely intervention/prevention of myosteatosis.

The fundamentals of sex-based disparity in liver transplantation: Understanding can lead to change

Liver transplantation (LT) is the definitive treatment for end-stage liver disease. Unfortunately, women are disadvantaged at every stage of the LT process. We conducted a literature review to increase the understanding of this disparity. Hormonal differences, psychological factors, and Model for End-Stage Liver Disease (MELD) score inequalities are some pretransplantation factors that contribute to this disparity. In the posttransplantation setting, women have differing risk than men in most major outcomes (perioperative complications, rejection, long-term renal dysfunction, and malignancy) and assessing the two groups together is disadvantageous. Herein, we propose interventions including standardized criteria for LT referral, using an alternate MELD, education for support of women, and motivating women to seek living donors. Understanding sex-based differences will allow us to improve access, tailor management, and improve overall outcomes for all patients, particularly women.

Body composition and the skeletal muscle compartment in liver transplantation: Turning challenges into opportunities

Frailty, nutritional status, and body composition are increasingly under the spotlight of interest in various clinical scenarios including liver transplantation. To address the rapidly accumulating evidence in this field, recent European and North American practice guidelines have clearly underlined the clinical importance of nutritional status and body composition with adopting their assessment in patients with liver disease and in transplant candidates into their recommendations. While earlier reports, and therefore present guidelines, were focusing predominantly on quantitative alterations of the skeletal muscle mass (sarcopenia), recent studies have identified qualitative alterations such as intramuscular fat accumulation (myosteatosis) and sarcopenic obesity as emerging risk factors for poor clinical outcomes. In this review, the role of body composition in the context of liver transplantation will be discussed with a focus on the skeletal muscle compartment. A brief overview of current assessment modalities including their limitations, diagnostic challenges, prognostic significance, and pathophysiology are included. Possibilities to incorporate body composition parameters into clinical decision making are discussed. In addition, novel trends and remaining challenges in the therapeutic targeting of body composition and the skeletal muscle compartment are highlighted.

Sarcopenia and frailty combined increases the risk of mortality in patients with decompensated cirrhosis

BACKGROUND

Both sarcopenia and frailty are prevalent in patients with decompensated cirrhosis and associated with negative outcomes. However, few studies investigated the impact of their coexistence on mortality. We aimed to evaluate the role of sarcopenia and frailty on survival in a cohort of hospitalized cirrhotics.

METHODS

This was an observational cohort study including 221 patients hospitalized for decompensated events. The cutoff for low skeletal muscle index (SMI) at the third lumbar vertebra level on computed tomography built by our previous work (male: SMI <46.96 cm2/m2; female: SMI <32.46 cm2/m2) was used for the diagnosis of sarcopenia. Individuals with a Frailty Index >0.38 were considered frail. The sample was divided into four groups: sarcopenia and frailty (SF); sarcopenia and non-frailty (SN); non-sarcopenia and frailty (NF); and non-sarcopenia and non-frailty (NN). Follow-up for survival lasted 2 years.

RESULTS

Sarcopenia and frailty were present in 21.7% and 14.5% of the patients, respectively. The frequency of frailty in the group of sarcopenic patients was significantly higher than in the patients without sarcopenia (27.1% versus 11%, p = 0.009). In the survival analysis, the SF group showed a higher hazard ratio (2.604 in model 1; 4.294 in model 2) for mortality when compared with the NN group. In addition, the concurrence of those two conditions does give rise to incremental risk for mortality when compared with the group with each disturbance separately, namely, the SN/NF group.

CONCLUSION

In conclusion, cirrhotic patients with sarcopenia and frailty combined showed higher mortality risk.

Sarcopenic obesity in liver disease: Handling both sides of the penny

Skeletal muscle and fat tissue show distinct pathophysiological roles and pivotal functions. The culmination of muscle wasting and fat accumulation represents an opposite terminal of each state. Specifically, this situation has been designated as sarcopenic obesity. However, sarcopenic obesity still lacks a unanimous definition, diagnostic criteria, and generalized modalities for assessment in the context of versatile liver diseases. Moreover, the underpinning mechanisms by which a combination of abnormal skeletal muscle and fat tissue leads to the progression of liver disease and impairs health‐related consequences are still elusive. Additionally, the interplay between skeletal muscle and fat, and the driving factors that shift different body compositions are not well understood. Therefore, in this review, we discuss skeletal muscle and fat components, with the purpose of conceptualization, as well as interpret their roles in liver diseases. We focus on the definitions, diagnostic criteria, and currently available measurements for sarcopenic obesity in the literature. We comprehensively discuss recent data and evidence regarding the potential role of sarcopenic obesity in the development and progression of numerous liver diseases and associated conditions, including nonalcoholic fatty liver disease, chronic viral hepatitis, cirrhosis, and liver transplantation. Furthermore, explicit information related to the pathogenesis of sarcopenic obesity from basic research is also provided in this narrative review. Finally, we discuss, from the clinical perspective of view, how to manage sarcopenic obesity using nutritional, physical, and pharmacological methods.

Changes in Body Adiposity in Women Undergoing Breast Cancer Treatment: A Scoping Review

Antineoplastic treatments can negatively affect body composition, leading to metabolic derangements and worse clinical outcomes in breast cancer patients. This scoping review assesses body adiposity changes during breast cancer therapy. We included clinical and observational studies, published until the last search date in any language, with women aged >18 years, after breast cancer diagnosis, at any clinical stage and with any history of breast cancer treatment, who had body adiposity quantified by imaging tools at least twice during follow-up. In total, 17 studies were included (n = 1,009 individuals), six of which found a significant increase in body adiposity during treatment, two found a significant decrease, one presented divergent findings according to the imaging method and the analyzed body adiposity depots, and eight studies found no significant change in the outcome. Selective estrogen receptor modulators were associated with increased body adiposity, whereas aromatase inhibitors were associated with its decrease (n = 3). Chemotherapy was associated with increased body adiposity (n = 1), and monoclonal antibody with reduced brown adipose tissue activity (n = 1). Breast cancer treatment may have different effects on body adiposity, according to its mechanisms and protocols. Further studies are necessary to better elucidate this scenario.

Diagnosis and Pathogenesis of Sarcopenia in Chronic Liver Disease Using Liver Magnetic Resonance Imaging

Background Liver magnetic resonance imaging (MRI) is rarely used to evaluate sarcopenia. This study sought to develop new diagnostic criteria for MRI in Asians and investigate the relationship between adipopenia and sarcopenia using MRI proton density fat fraction (PDFF), which is correlated with body fat mass. Methodology This study included 512 patients with chronic liver disease (CLD) who underwent magnetic resonance elastography (MRE). The following parameters were assessed: paraspinal muscle area/height index (PSMI) measured at the level of the superior mesenteric artery and PDFF. The cutoff PSMI and PDFF values for the diagnosis of sarcopenia and adipopenia, respectively, were determined using receiver operating characteristic analysis of Asians with low body mass index. Results Among patients with CLD, the prevalence rates of sarcopenia and adipopenia were 25% and 17%, respectively. We found that sarcopenia increased from stage 3 fibrosis and was inversely correlated with steatosis grade. Multivariate analysis found that MRI-PDFF was associated with sarcopenia. The Kaplan-Meier method in cirrhosis (n = 122) showed that the non-sarcopenia, sarcopenia, and sarcopenia/adipopenia groups had three-year survival rates of 97%, 55% (p < 0.01), and 23%, respectively. The Cox proportional hazards model identified the Child-Pugh score and sarcopenia/adipopenia as independent prognostic factors. Conclusions The new diagnostic criteria for sarcopenia confirmed that the prognosis of cirrhosis can be stratified. Furthermore, sarcopenia with adipopenia was shown to be a phenotype of severe sarcopenia in cirrhosis, and screening for sarcopenia should include cases in the precirrhotic stage.

Skeletal Muscle Pathological Fat Infiltration (Myosteatosis) Is Associated with Higher Mortality in Patients with Cirrhosis

Myosteatosis (pathological fat accumulation in muscle) is defined by lower mean skeletal muscle radiodensity in CT. We aimed to determine the optimal cut-offs for myosteatosis in a cohort of 855 patients with cirrhosis. CT images were used to determine the skeletal muscle radiodensity expressed as Hounsfield Unit (HU). Patients with muscle radiodensity values below the lowest tertile were considered to have myosteatosis. Competing-risk analysis was performed to determine associations between muscle radiodensity and pre-transplant mortality. Muscle radiodensity less than 33 and 28 HU in males and females, respectively, were used as cut-offs to identify myosteatosis. In the univariate analysis, cirrhosis etiology, MELD score, refractory ascites, variceal bleeding, hepatic encephalopathy, sarcopenia and myosteatosis were predictors of mortality. Myosteatosis association with mortality remained significant after adjusting for confounding factors (sHR 1.47, 95% CI 1.17−1.84, p = 0.001). Patients with concurrent presence of myosteatosis and sarcopenia constituted 17% of the patient population. The cumulative incidence of mortality was the highest in patients with concomitant sarcopenia and myosteatosis (sHR 2.22, 95% CI 1.64−3.00, p < 0.001). In conclusion, myosteatosis is common in patients with cirrhosis and is associated with increased mortality. The concomitant presence of myosteatosis and sarcopenia is associated with worse outcomes.

Myosteatosis in Cirrhosis: A Review of Diagnosis, Pathophysiological Mechanisms and Potential Interventions

Myosteatosis, or pathological excess fat accumulation in muscle, has been widely defined as a lower mean skeletal muscle radiodensity on computed tomography (CT). It is reported in more than half of patients with cirrhosis, and preliminary studies have shown a possible association with reduced survival and increased risk of portal hypertension complications. Despite the clinical implications in cirrhosis, a standardized definition for myosteatosis has not yet been established. Currently, little data exist on the mechanisms by which excess lipid accumulates within the muscle in individuals with cirrhosis. Hyperammonemia may play an important role in the pathophysiology of myosteatosis in this setting. Insulin resistance, impaired mitochondrial oxidative phosphorylation, diminished lipid oxidation in muscle and age-related differentiation of muscle stem cells into adipocytes have been also been suggested as potential mechanisms contributing to myosteatosis. The metabolic consequence of ammonia-lowering treatments and omega-3 polyunsaturated fatty acids in reversing myosteatosis in cirrhosis remains uncertain. Factors including the population of interest, design and sample size, single/combined treatment, dosing and duration of treatment are important considerations for future trials aiming to prevent or treat myosteatosis in individuals with cirrhosis.

Higher subcutaneous adipose tissue radiodensity is associated with increased mortality in patients with cirrhosis

Background & Aims

Association between sarcopenia and mortality in cirrhosis is well recognised; however, little is known about the clinical implications of adipose tissue radiodensity, indicative of biological features. This study aimed to determine an association between high subcutaneous adipose tissue (SAT) radiodensity and survival, compare the prevalence of high SAT radiodensity between healthy population and patients with cirrhosis, and identify an association between computed tomography (CT)-measured SAT radiodensity and histological characteristics.

Methods

Adult patients with cirrhosis (n = 786) and healthy donors (n = 129) with CT images taken as part of the liver transplant (LT) assessment were included. Abdominal SAT biopsies (1–2 g) were harvested from the incision site at the time of LT from 12 patients with cirrhosis.

Results

The majority of patients were male (67%) with a mean model for end-stage liver disease (MELD) score of 15 ± 8. SAT radiodensity above -83 HU in females (sub-distribution hazard ratio [sHR] 1.84, 95% CI 1.20–2.85, p = 0.006) and higher than -74 HU in males (sHR 1.51, 95% CI 1.05–1.18, p = 0.02) was associated with the highest mortality risk after adjusting for confounders in competing risk analysis. The frequency of high SAT radiodensity was 26% for those with cirrhosis, compared with 2% in healthy donors (p <0.001). An inverse correlation was found between SAT radiodensity and the mean cross-sectional area of SAT adipocytes (r = -0.67, p = 0.02). Shrunken, smaller adipocytes with expanded interstitial space were predominant in patients with high SAT radiodensity, whereas larger adipocytes with a thin rim of cytoplasm were observed in patients with low SAT radiodensity (744 ± 400 vs. 1,521 ± 1,035 μm², p <0.001).

Conclusion

High SAT radiodensity frequently presents and is associated with a higher mortality in cirrhosis. SAT morphological rearrangement in patients with high SAT radiodensity might indicate diminished lipid stores and alterations in tissue characteristics.

Lay summary

Poor quality of subcutaneous adipose tissue (fat under the skin) is associated with higher mortality in patients with end-stage liver disease. Fat cells are smaller in patients with poor adipose tissue quality.

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Subcutaneous adipose tissue (SAT) radiodensity can be objectively measured by CT in Hounsfield units (HU).

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SAT radiodensity constitutes an indirect surrogate marker of adipose tissue quality.

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High SAT radiodensity in cirrhosis was defined as >-83 HU in females and >-74 HU in males.

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High SAT radiodensity presents in more than a quarter of patients with cirrhosis and is associated with higher mortality.

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High SAT radiodensity might indicate adipose tissue remodelling with morphological features of atrophy.

Sarcopenia in Patients with Cirrhosis after Transjugular Intrahepatic Portosystemic Shunt Placement

Background Sarcopenia is frequently found in patients with cirrhosis and is associated with liver dysfunction, cirrhosis-related complications, and poorer quality of life. Purpose To evaluate changes in skeletal muscle and fat mass at CT and to evaluate the relationship of sarcopenia to mortality in patients with cirrhosis after transjugular intrahepatic portosystemic shunt (TIPS) placement. Materials and Methods Patients who underwent TIPS between August 2016 and May 2020 were included in this retrospective study. Skeletal muscle and fat mass were evaluated at CT at the L3 vertebra at baseline and at 2 months, 5 months, and 1 year after TIPS. Sarcopenia was defined as L3 skeletal muscle index (SMI) less than 50 cm²/m² for men and less than 39 cm²/m² for women. The primary end point was change in skeletal muscle and fat mass, and secondary end points included survival and the predictive factors for survival. Changes in skeletal muscle and fat mass over time were analyzed by generalized estimating equations. Results A total of 224 patients (159 men [113 with and 46 without sarcopenia] and 65 women [32 with and 33 without sarcopenia]) were included. In male patients with sarcopenia, the mean L3 SMI increased from 41.8 cm²/m² (baseline) to 49.1 cm²/m² (at 5-month follow-up; P < .001) and 49.6 cm²/m² (at 1-year follow-up; P < .001) after TIPS. In female patients with sarcopenia, SMI increased from 33.7 cm²/m² (at baseline) to 40.6 cm²/m² (at 5-month follow-up; P < .001) and 42.0 cm²/m² (at 1-year follow-up; P < .001) after TIPS. Sarcopenia (hazard ratio, 3.0; 95% CI: 1.2, 7.8) was identified as an independent risk factor for mortality after TIPS, and the patients who converted from sarcopenic to nonsarcopenic had higher cumulative survival rate than those who did not (96.4% vs 82.1%; log-rank P = .04). Conclusion In patients with sarcopenia, both skeletal muscle and fat mass increased after transjugular intrahepatic portosystemic shunt placement. The reversal of sarcopenia could reduce the risk of death. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Lee in this issue.

Risk of falls in patients with cirrhosis evaluated by timed up and go test: Does muscle or brain matter more?

BACKGROUND

Minimal hepatic encephalopathy (MHE) is considered a risk factor for falls in patients with liver cirrhosis. However, MHE is prevalent in patients with muscle alterations (sarcopenia and myosteatosis) probably due to the role of muscle in ammonia handling.

AIM

To assess the respective role of muscle alterations and MHE on the risk of falls in cirrhotic patients.

METHODS

Fifty cirrhotics were studied for MHE detection by using Psychometric Hepatic Encephalopathy Score (PHES) and Animal Naming Test (ANT). CT scan was used to quantify the skeletal muscle index (SMI) and muscle attenuation, as a measure of myosteatosis. The risk of falls was evaluated by the Timed Up&Go test (TUG). The occurrence of falls during follow up was also detected.

RESULTS

32 patients (64%) had an abnormal TUG (< 14 s). In the group with TUG ≥ 14 s, MHE (72vs31%, p<0.005) and myosteatosis (94vs50%, p = 0.002) were significantly more frequent than in patients with TUG<14 s. At multivariate the variables independently associated to TUG ≥ 14 s were myosteatosis, MHE and chronic beta-blockers use. During a mean follow-up of 25±16.9 months, 12 patients fell; the percentage of falls was significantly higher in patients with TUG ≥ 14 s (50%vs9%, p = 0.001) as well as in patients with myosteatosis (33%vs6%, p = 0.03), but similar in patients with or without MHE (35%vs15%, NS).

CONCLUSION

In cirrhotic patients both muscle alterations and cognitive impairment, as well as chronic beta-blockers use, are associated to the risk of falls.

Defining reference values for low skeletal muscle index at the L3 vertebra level based on computed tomography in healthy adults: A multicentre study

BACKGROUND & AIMS

Skeletal muscle mass loss is an important aspect of malnutrition and is closely related to adverse clinical outcomes. Computed tomography (CT) is the gold standard for analysing muscle mass, and the skeletal muscle index at the third lumbar vertebra (L3-SMI), measured using CT, is an important indicator to evaluate total skeletal tissue. The aims of this study were to establish reference values for low L3-SMI in Northern China, and to investigate the correlation between L3-SMI and age, and the correlation between L3-SMI and body mass index (BMI).

METHODS

This was a multicentre, retrospective, cross-sectional study. A search of abdominal CT imaging reports, using specific keywords, was conducted in four representative cities in northern China, from January 2016 to March 2021. Transverse CT images at the level of the third lumbar vertebra (L3) were identified, exported from the Radiology Information System, and measured using the analysis software SliceOmatic. Statistical analyses were performed using SPSS 24.0, and significance level was set at p < 0.05. Mean, standard deviations (SD) and percentiles (p5, p10, p25, p50, p75, p90, p95) were used to describe the distribution of L3-SMI in the study population. Low skeletal muscle index was defined as a 5% percentile, or two standard deviations below the mean value of younger healthy individuals (age 20-39 years).

RESULTS

The study included 1787 healthy individuals, with a median age of 45 (25) years (range 20-88 years), and a median BMI of 23.1 (4.1) kg/m2 (range 18.5-38.7 kg/m2). Among them, 700 healthy individuals (39.1%) were aged 20-39 years. L3-SMI had a negative linear correlation with age, and a positive linear correlation with BMI. The L3-SMI reference values used to define low skeletal muscle mass loss in the Northern Chinese population, using the 5% percentile, were 40.2 cm2/m2 in men, and 31.6 cm2/m2 in women. Using the mean minus two standard deviations protocol, the reference values were 37.9 cm2/m2 and 28.6 cm2/m2 in men and women, respectively.

CONCLUSIONS

This study analysed the human body composition of 1787 healthy people in four cities in northern China, using CT, and established diagnostic thresholds of skeletal muscle mass depletion based on 700 younger healthy adults, using the 5% percentile and mean-2SD methods. These reference values can be used to diagnose malnutrition in patients and may aide clinicians in predicting prognosis and improving nutritional therapy. Further research is warranted to determine the prognostic role of reference values against clinical outcomes in different disease populations.

Prediction of Patient Survival with Psoas Muscle Density Following Transjugular Intrahepatic Portosystemic Shunts: A Retrospective Cohort Study

Background

Psoas muscle density (PMD) as a nutritional indicator is a tool to evaluate sarcopenia, which is commonly diagnosed in patients with liver cirrhosis. However, there are limited data on its role in patients who have received a transjugular intrahepatic portosystemic shunt (TIPS). We aimed to determine the utility of PMD in predicting mortality of patients with TIPS implantation and to compare the clinical value of PMD, Child-Pugh score, model for end-stage liver disease (MELD) score, and MELD paired with serum sodium measurement (MELD-Na) score in predicting post-TIPS survival in 1 year.

Material/Methods

This retrospective study included 273 patients who met the criteria for study inclusion. All participants underwent computed tomography (CT) scans, Child-Pugh score evaluation, MELD-Na scoring, and MELD scoring. Post-TIPS survival time was estimated using the Kaplan-Meier survival curve. The prognostic values of scoring models such as the Child-Pugh score, MELD, MELD-Na, and PMD were evaluated using receiver operating characteristic curves.

Results

During the 1-year follow-up period, 31 of 273 (11.36%) post-TIPS patients died. Multivariate analysis identified PMD as an independent protective factor. PMD showed a good ability to predict the occurrence of an endpoint within 1 year after TIPS. The area under the receiver operating characteristic curves for PMD, Child-Pugh score, MELD score, and MELD-Na for predicting mortality were, respectively, 0.72 (95% confidence interval [CI]: 0.663–0.773), 0.59 (95% CI: 0.531–0.651), 0.60 (95% CI: 0.535–0.655), and 0.58 (95% CI: 0.487–0.608).

Conclusions

PMD has appreciable clinical value for predicting the mortality of patients with TIPS implantation. In addition, PMD is superior to established scoring systems for identifying high-risk patients with a poor prognosis.

Comorbidities impact and de-prescribing in elderly with HCV-related liver disease: analysis of a prospective cohort

Management for HCV has undergone a notable change using direct-acting antiviral drugs (DAAs), which are safe and effective even in elderly. Here, we define impact of comorbidities, concomitant medication and drug-drug interactions in elder patients with HCV related disease before starting DAAs regimen. We analyzed data of 814 patients prospectively enrolled at our Unit within the web based model HCV Sicily Network. Out of 814, 590 were treated with DAAs and 414 of them were older than 65 years. We divided those 414 in two groups, one including 215 patients, aged between 65 and 74 years, and another with 199 patients, aged of 75 years and over. Charlson Comorbidity Index (CCI) was assessed for each patient; drug-drug interactions (DDI) and de-prescribing process were carried out appropriately. Within 414 patients included, percentage rates of women treated was higher than males, BMI was lower and cirrhosis was frequently reported in patients older than 75 years. Hypertension, diabetes mellitus, dyslipidemia (p < 0.0001), prostatic pathologies, kidney disease, gastrointestinal disease (p < 0.0001), osteoporosis (p < 0.01) and depression were most common co-morbidities. CCI showed lower scores in the first group as compared with the second one (p < 0.0001). Among drugs, statins were frequently suspended and anti-hypertensive often replaced. DAAs are useful and effective regardless of disease severity, comorbidities, medications and age. De-prescribing allows a stable reduction of number of medications taken with real improvement of quality of life.

The improvement in body composition including subcutaneous and visceral fat reduces ammonia and hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

BACKGROUND

Sarcopenia and myosteatosis have been associated to a poor prognosis of cirrhosis and to a higher incidence of hepatic encephalopathy (HE). The prognostic implications of visceral and subcutaneous adiposity are less known.

AIM

To evaluate the modifications of visceral and subcutaneous adipose tissue after TIPS and to investigate their relationships with the modification of muscle mass and with the incidence of post-TIPS HE.

PATIENTS AND METHODS

35 cirrhotic patients submitted to TIPS were retrospectively studied. The modification of skeletal muscle index (SMI), muscle attenuation (myosteatosis), subcutaneous adipose tissue index (SATI), visceral adipose tissue index (VATI), assessed by CT-scan and plasma ammonia were evaluated before and after a mean follow-up of 19 ± 15 months after TIPS. The number of episodes of overt HE was also recorded.

RESULTS

During the follow-up, the mean SMI and muscle attenuation increased significantly; SATI significantly increased while VATI significantly decreased, although not uniformly in all patients. By comparing the patients with or without improvement in their nutritional status after TIPS, MELD remained stable while the number of episodes of overt HE was significantly lower in the patients with improved SMI and in the patients with improved SATI. Finally, inverse correlation was observed between the variation of ammonia and SATI (r = -.40; P < .05).

CONCLUSION

In addition to muscle mass, adipose tissue is modified after TIPS. The improvement of subcutaneous adipose tissue as well as of sarcopenia and myosteatosis is associated to the amelioration of cognitive impairment independently of liver function. The correlation between adipose tissue and ammonia modification may suggest an active role of the adipose tissue in the inter-organ ammonia trafficking.

Visceral Adiposity Associates With Malnutrition Risk Determined by Royal Free Hospital-Nutritional Prioritizing Tool in Cirrhosis

Mounting evidence has suggested the clinical significance of body composition abnormalities in the context of cirrhosis. Herein, we aimed to investigate the association between visceral adiposity and malnutrition risk in 176 hospitalized patients with cirrhosis. The adiposity parameters were obtained by computed tomography (CT) as follows: total adipose tissue index (TATI), visceral adipose tissue index (VATI), subcutaneous adipose tissue index (SATI), and visceral to subcutaneous adipose tissue area ratio (VSR). Malnutrition risk was screened using Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT). Visceral adiposity was determined given a higher VSR based on our previously established cutoffs. Multivariate analysis implicated that male gender (OR = 2.884, 95% CI: 1.360-6.115, p = 0.006), BMI (OR = 0.879, 95% CI: 0.812-0.951, P = 0.001), albumin (OR = 0.934, 95% CI: 0.882-0.989, P = 0.019), and visceral adiposity (OR = 3.413, 95% CI: 1.344-8.670, P = 0.010) were independent risk factors of malnutrition risk. No significant difference was observed regarding TATI, SATI, and VATI among patients with low or moderate and high risk of malnutrition. In contrast, the proportion of male patients embracing visceral adiposity was higher in high malnutrition risk group compared with that in low or moderate group (47.27 vs. 17.86%, p = 0.009). Moreover, this disparity was of borderline statistical significance in women (19.05 vs. 5.88%, p = 0.061). Assessing adipose tissue distribution might potentiate the estimation of malnutrition risk in cirrhotics. It is pivotal to recognize visceral adiposity and develop targeted therapeutic strategies.

Risks and Rewards of Bariatric Surgery in Advanced Chronic Liver Diseases

The burden of obesity and metabolic syndrome has determined a sharp increase in bariatric surgery (BS) procedures, which lead to marked weight loss, improved metabolic syndrome, reduced cardiovascular risk, and even improvement in nonalcoholic steatohepatitis (NASH). Despite these promising results, BS in patients with chronic liver disease can rarely lead to worsening of liver function, progression to cirrhosis and its complications, and even liver transplantation. On the other hand, since obesity in patients with cirrhosis is a major cofactor for progression to a decompensated stage of the disease and a risk factor for hepatocellular carcinoma, BS has been used to achieve weight loss in this population. In this review, we critically analyze the existing data on outcomes of BS in patients with cirrhosis and the possible mechanisms leading to fibrosis progression and worsening liver function in patients undergoing BS. Finally, we propose a set of measures that could be taken to improve the multidisciplinary management of liver disease in patients undergoing BS, including early recognition of malnutrition and alcohol misuse.

Computed Tomography-Determined Body Composition Abnormalities Usefully Predict Long-term Mortality in Patients With Liver Cirrhosis

OBJECTIVE

We evaluated the prognostic impacts of body composition components measured by computed tomography (CT) in patients with liver cirrhosis.

METHODS

A total of 160 cirrhotic patients who underwent CT and hepatic venous pressure gradient measurements were retrospectively enrolled. Cross-sectional areas of skeletal muscle, visceral and subcutaneous fat, and mean CT attenuation of trabecular bone of the fourth lumbar vertebral level (L4HU) were measured.

RESULTS

Multivariate analysis showed model for end-stage liver disease score [hazard ratio (HR), 1.086; 95% confidence interval (CI), 1.020-1.156; P = 0.010], hepatic venous pressure gradient (HR, 1.076; 95% CI, 1.021-1.135; P = 0.006), sarcopenia (HR, 1.890; 95% CI, 1.032-3.462; P = 0.039), and L4HU (HR, 1.960 for L4HU <145 Hounsfield units; 95% CI, 1.094-3.512; P = 0.024) were independently associated with long-term mortality. In patients with decompensated cirrhosis, subcutaneous adipose tissue index was the only independent predictor (HR, 0.984; 95% CI, 0.969-0.999; P = 0.039).

CONCLUSION

Body composition abnormalities determined by CT are associated with long-term prognosis in cirrhotic patients.

Significance of Adipose Tissue Maintenance in Patients Undergoing Hemodialysis

In the general population, obesity is known to be associated with adverse outcomes, including mortality. In contrast, high body mass index (BMI) may provide a survival advantage for hemodialysis patients, which is known as the obesity paradox. Although BMI is the most commonly used measure for the assessment of obesity, it does not distinguish between fat and lean mass. Fat mass is considered to serve as an energy reserve against a catabolic condition, while the capacity to survive starvation is also thought to be dependent on its amount. Thus, fat mass is used as a nutritional marker. For example, improvement of nutritional status by nutritional intervention or initiation of hemodialysis is associated with an increase in fat mass. Several studies have shown that higher levels of fat mass were associated with better survival in hemodialysis patients. Based on body distribution, fat mass is classified into subcutaneous and visceral fat. Visceral fat is metabolically more active and associated with metabolic abnormalities and inflammation, and it is thus considered to be a risk factor for cardiovascular disease and mortality. On the other hand, subcutaneous fat has not been consistently linked to adverse phenomena and may reflect nutritional status as a type of energy storage. Visceral and subcutaneous adipose tissues have different metabolic and inflammatory characteristics and may have opposing influences on various outcomes, including mortality. Results showing an association between increased subcutaneous fat and better survival, along with other conditions, such as cancer or cirrhosis, in hemodialysis patients have been reported. This evidence suggests that fat mass distribution (i.e., visceral fat and subcutaneous fat) plays a more important role for these beneficial effects in hemodialysis patients.