Both sarcopenia and frailty determine suitability of patients for liver transplantation-A systematic review and meta-analysis of the literature

Telemedicine in Patients Affected by Chronic Liver Disease: A Scoping Review of Clinical Outcomes and the Devices Evaluated

For patients with chronic liver disease (CLD), telemedicine is emerging as a useful tool to prevent liver decompensation or hospitalization, allowing access to and the decentralization of care, even for patients with limited resources. However, research and attendant evidence are still lacking; thus, this review aims to systematically explore the topic of telemonitoring for CLD to describe the currently used tools and clinical outcomes. The review was conducted by using key terms on PubMed/EMBASE and searching for observational studies or clinical trials (according to PRISMA recommendations) that were published between 6 April 2013 and 6 April 2023 to keep the technological framework limited to the last 10 years. The studies were described and grouped according to the aim of telemonitoring, the underlying disease, and the tools adopted to achieve remote monitoring. A total of 32 articles met the inclusion criteria. Of these, 11 articles report the successful use of a telehealth program to support and improve access to care in the management of HCV-related cirrhosis, eight articles examine the efficacy of telemedicine for remote monitoring interventions to prevent or decrease the risk of decompensation in high-risk patients, and five articles examine improvements in the physical performance and quality of life of cirrhotic patients through telehealth rehabilitation programs. Four studies were completed during the recent COVID-19 pandemic. Telehealth has the potential to provide and expand treatment access and reduce barriers to care for the most disadvantaged patients and might be able to reduce the need for hospital readmission for CLD, though most practice to test feasibility is still in the pilot stage.

Frailty and Pre-Frailty in the Setting of Total Joint Arthroplasty: A Narrative Review

Background

Total joint arthroplasties are among the most common surgical procedures performed in the United States. Although numerous safeguards are in place to optimize patient health and safety pre-, intra-, and postoperatively, patient frailty is often incompletely assessed or not assessed at all. Frailty has been shown to increase rates of adverse events and length of stay. We discuss the impact of frailty on patient outcomes and healthcare economics as well as provide widely accepted models to assess frailty and their optimal usage.

Methods

Several databases were searched using the keywords "frailty," "TJA," "THA," "frailty index," "frailty assessment," and "frailty risk." A total of 45 articles were used in this literature review.

Results

It is estimated that nearly half of patients over the age of 85 meet criteria for frailty. Frailty in surgical patients has been shown to increase total costs as well as length of stay. Additionally, increased rates of numerous adverse events are associated with increased frailty.

Conclusions

The literature demonstrates that frailty poses increased risk of adverse events, increased length of stay, and increased cost. There are several models that accurately assess frailty and can feasibly be implemented into preoperative screening.

Identifying Outcome Domains for Clinical Trials of Physical Rehabilitation Among Adults Undergoing Solid Organ Transplantation Using a Delphi Approach

Introduction: A core outcome set (COS) improves the quality of reporting in clinical trials; however, this has not been developed for clinical trials of exercise training among adults undergoing solid organ transplant. Research Question: To explore the perspectives of transplant patients and healthcare professionals on the key outcomes domains that are relevant for clinical trials of exercise in all recipients of transplanted organs. Methods: A Delphi approach was employed with 2 rounds of online questionnaires. Participants rated the importance of outcome domains using a 9-point Likert scale ranging from "not important" to "very important". A score of 7 to 9 (very important) by 70% or more participants and a score of 1 to 3 (not important) by less than 15% participants were required to keep an outcome domain from the first to the second round. Results: Thirty-six participants completed 2 rounds of questionnaires (90% response rate). After Round 1, 8 outcome domains were considered very important in the pretransplant phase; 16 in the early posttransplant; and 17 in the late posttransplant. Only 1 outcome domain, organ rejection in the early posttransplant phase, met the criteria to be considered very important after Round 2. Conclusion: Although consensus was not reached on the core outcome domains, this study provides preliminary information on which domains are higher priority for patients and professionals. Future work should consider a meeting with key stakeholders to allow for deeper discussion to reach consensus on a core outcome set.

Home-based intensive nutrition therapy improves frailty and sarcopenia in patients with decompensated cirrhosis: A randomized clinical trial

BACKGROUND AND AIM

The majority of patients with decompensated cirrhosis suffer from malnutrition, a potentially modifiable contributor to frailty and sarcopenia. The present study investigated the impact of a 6-month dietician-supported home-based intensive nutrition therapy (HINT) intervention on objective frailty and sarcopenia metrics in patients with decompensated cirrhosis.

METHODS

One hundred adult patients with decompensated cirrhosis, frailty, and sarcopenia at baseline were randomized 1:1 to receive standard medical therapy (SMT) plus HINT (intervention) versus SMT (control) alone. The primary outcome was an improvement in frailty as measured by the liver frailty index (LFI). Secondary outcome measures included sarcopenia metrics, liver disease severity scores, hospitalization, and death.

RESULTS

The LFI improved more in the intervention arm as compared with controls (0.8 vs 0.4; P < 0.001). Baseline and end-of-study skeletal muscle index (SMI) was available in a subset of 32 male patients, with greater improvements seen in the intervention arm compared with controls (6.36 vs 0.80; P = 0.02). Patients in the intervention arm had less hospitalizations over the 6-month follow-up (19 [38%] vs 29 [58%]; P = 0.04). On subgroup analysis, in the 64% of patients who were adherent to calorie and protein intake targets at 6 months, significant improvement was seen in liver disease severity scores and survival (P < 0.05).

CONCLUSION

In patients with decompensated cirrhosis, frailty, and sarcopenia, a 6-month dietitian-supported home-based intensive outpatient nutrition therapy was associated with statistically and clinically relevant improvement in frailty. The subgroup of adherent patients showed improvement in their liver disease scores and reduction in mortality. These findings support the key role of food as medicine in the management of cirrhosis.

Frailty and solid-organ transplant candidates: a scoping review

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.

Divergent trajectories of lean vs obese non-alcoholic steatohepatitis patients from listing to post-transplant: A retrospective cohort study

BACKGROUND

Non-alcoholic steatohepatitis (NASH) cirrhosis is the second most common indication for liver transplantation (LT). The role of body mass index (BMI) on outcomes of NASH cirrhosis has been conflicting.

AIM

To compare the longitudinal trajectories of patients with lean vs obese NASH cirrhosis, from listing up to post-transplant, having adjusted their BMI for ascites.

METHODS

We retrospectively reviewed all adult NASH patients listed for LT in our program from 2012 to 2019. Fine-Gray Competing Risk analyses and Cox Proportional-Hazard Models were performed to examine the cumulative incidence of transplant and survival outcomes respectively.

RESULTS

Out of 265 NASH cirrhosis listed patients, 176 were included. Median age was 61.0 years; 46% were females. 111 patients underwent LT. Obese robust patients had better waitlist survival [hazard ratio (HR): 0.12; 95%CI: 0.05–0.29, P < 0.0001] with higher instantaneous rate of transplant (HR: 5.71; 95%CI: 1.26–25.9, P = 0.02). Lean NASH patients had a substantially higher risk of graft loss within 90 d post-LT (1.2% vs 13.8%, P = 0.032) and death post-LT (2.4% vs 17.2%, P = 0.029). 1- 3- and 5-year graft survival was poor for lean NASH (78.6%, 77.3% and 41.7% vs 98.6%, 96% and 85% respectively). Overall patient survival post-LT was significantly worse in lean NASH (HR: 0.17; 95%CI: 0.03–0.86, P = 0.0142) with 83% lower instantaneous rate of death in obese group.

CONCLUSION

Although lean NASH is considered to be more benign than obese NASH, our study suggests a paradoxical correlation of lean NASH with waitlist outcomes, and graft and patient survival post-LT.

Impact of pretransplant frailty and sarcopenia on the post-transplant prognosis of patients with liver cirrhosis: a systematic review

INTRODUCTION

Frailty and sarcopenia associate with increased mortality in patients with liver cirrhosis on the transplant waitlist. We conducted a systematic review on the impact of pretransplant frailty and sarcopenia on post-transplant outcomes in adult patients with liver cirrhosis.

METHODS

We performed a search in Medline, Embase and Cochrane Central. Of the 12276 references initially recovered, 34 were included.

RESULTS

Frailty and sarcopenia presented a negative impact on post-transplant outcomes and seemed to associate with an overall two-fold reduction in early and 50% reduction in late survival, for severe conditions, according to the largest cohorts. These patients required longer ICU and hospitalization time, had higher rates of sepsis and respiratory complications and lower graft-survival. The reversibility of frailty depended on the severity of functional impairment and on the co-morbidities contributing to frailty. Reversibility of sarcopenia occurred in only a minority of patients, in unbiased studies.

CONCLUSION

Frailty and sarcopenia are double-edged swords: patients with frailty/sarcopenia should be prioritized for liver transplantation due to increased mortality on the waitlist; however, severe frailty/sarcopenia may justify delisting because it associates with dismal prognosis post-liver transplantation. Patients presenting mild to moderate frailty/sarcopenia, should be submitted to liver transplantation before those conditions worsen to a level that significantly impacts post-liver transplantation outcomes.

Propensity Score-Matched Analysis of Posttransplant Outcomes in Living Donor Liver Transplantation for Older Adult Recipients

The impact of increasing recipient age on morbidity and mortality following living donor liver transplantation (LDLT) remains controversial. The study aims to analyze the impact of recipient age on outcomes following LDLT. Data on adult LDLTs performed between November 2009 and February 2020 were retrieved from a prospectively maintained database. Patients were stratified into 2 groups based on recipient age: 18 to 65 years (younger adults) and >65 years (older adults). Propensity score matching (PSM) using nearest-neighbor matching was used to match each older recipient with up to 2 younger adult recipients using multiple preoperative parameters. Outcomes evaluated were duration of ventilation, need for reintubation, tracheostomy, intensive care unit (ICU) readmission, length of ICU and hospital stays, postoperative complications, reoperation within 90 days, and patient survival. A total of 801 adult LDLT recipients were included in the study; 751 (93.7%) were younger adults, and 50 (6.3%) were older adults. Older recipients were more likely to be diabetic (60.0% versus 39.7%) and hypertensive (44.0% versus 20.4%) with preexisting cardiac disease (28.0% versus 11.2%). However, their pretransplant Model for End-Stage Liver Disease score was significantly lower (14.5 versus 17.7), and they were more likely to receive a transplant because of hepatocellular carcinoma (38.0% versus 17.7%). Older recipients had longer durations of ventilation after LT both before (3.7 versus 1.9 days) and after PSM (4.0 versus 1.5 days). After PSM, the 30-day (13.0% versus 2.4%), 90-day (15.2% and 2.4%), and overall mortality rates (21.7% versus 7.1%) were significantly higher for older recipients when compared with younger recipients. There was no difference between the younger and older recipients with respect to other postoperative outcomes. This propensity score-matched study shows that the older LDLT recipients have higher 30-day, 90-day, 1-year, and 5-year mortality rates when compared with matched younger counterparts.

Relationship between sarcopenia/myosteatosis and frailty in hospitalized patients with cirrhosis: a sex-stratified analysis

Background:

Previous studies have shown that sarcopenia appears to be a significant contributor to physical frailty among outpatients with cirrhosis. However, the evidence is scant regarding the relationship between sarcopenia and multi-dimensional frailty among inpatients. We aimed to investigate the potential contribution of sarcopenia to frailty in hospitalized patients with cirrhosis in a sex-dependent manner.

Methods:

This cohort enrolled consecutive cirrhotics. Muscle quantity and quality were assessed using the computed tomography-based skeletal muscle index (SMI) and intramuscular adipose tissue content, respectively. Frailty phenotype was clarified by a self-reported Frailty Index. Multiple linear regression determined the association between sarcopenia and frailty phenotype.

Results:

A total of 202 cirrhotic patients with 48.5% male were included. The median Frailty Index was 0.13, rendering 17.3% subjects as frail. Among the 16 frail men, 68.8% had sarcopenia and 62.5% exhibited myosteatosis. In contrast, among the 19 frail women, 26.3% had sarcopenia and 15.8% exhibited myosteatosis. Frail patients had a significantly lower median SMI (42.80 cm²/m²) compared with those with pre-frailty (48.23 cm²/m²) and with robust status (50.82 cm²/m²) in the male but not the female group. In male patients, multivariate linear regression implicated age (β = 0.330, p < 0.001), SMI (β = −0.260, p < 0.001), albumin (β = −0.245, p = 0.005), and sodium (β = −0.179, p = 0.037) as independent risk factors for frailty.

Conclusion:

Sarcopenia is associated with multi-dimensional frailty in male patients with cirrhosis. It is tempting to incorporate sex-specific intervention with the purpose of mitigating frailty among inpatients.

Evidence-based clinical practice guidelines for Liver Cirrhosis 2020

The first edition of the clinical practice guidelines for liver cirrhosis was published in 2010, and the second edition was published in 2015 by the Japanese Society of Gastroenterology (JSGE). The revised third edition was recently published in 2020. This version has become a joint guideline by the JSGE and the Japan Society of Hepatology (JSH). In addition to the clinical questions (CQs), background questions (BQs) are new items for basic clinical knowledge, and future research questions (FRQs) are newly added clinically important items. Concerning the clinical treatment of liver cirrhosis, new findings have been reported over the past 5 years since the second edition. In this revision, we decided to match the international standards as much as possible by referring to the latest international guidelines. Newly developed agents for various complications have also made great progress. In comparison with the latest global guidelines, such as the European Association for the Study of the Liver (EASL) and American Association for the Study of Liver Diseases (AASLD), we are introducing data based on the evidence for clinical practice in Japan. The flowchart for nutrition therapy was reviewed to be useful for daily medical care by referring to overseas guidelines. We also explain several clinically important items that have recently received focus and were not mentioned in the last editions. This digest version describes the issues related to the management of liver cirrhosis and several complications in clinical practice. The content begins with a diagnostic algorithm, the revised flowchart for nutritional therapy, and refracted ascites, which are of great importance to patients with cirrhosis. In addition to the updated antiviral therapy for hepatitis B and C liver cirrhosis, the latest treatments for non-viral cirrhosis, such as alcoholic steatohepatitis/non-alcoholic steatohepatitis (ASH/NASH) and autoimmune-related cirrhosis, are also described. It also covers the latest evidence regarding the diagnosis and treatment of liver cirrhosis complications, namely gastrointestinal bleeding, ascites, hepatorenal syndrome and acute kidney injury, hepatic encephalopathy, portal thrombus, sarcopenia, muscle cramp, thrombocytopenia, pruritus, hepatopulmonary syndrome, portopulmonary hypertension, and vitamin D deficiency, including BQ, CQ and FRQ. Finally, this guideline covers prognosis prediction and liver transplantation, especially focusing on several new findings since the last version. Since this revision is a joint guideline by both societies, the same content is published simultaneously in the official English journal of JSGE and JSH.

Evidence-based clinical practice guidelines for liver cirrhosis 2020

The first edition of the clinical practice guidelines for liver cirrhosis was published in 2010, and the second edition was published in 2015 by the Japanese Society of Gastroenterology (JSGE). The revised third edition was recently published in 2020. This version has become a joint guideline by the JSGE and the Japanese Society of Hepatology (JSH). In addition to the clinical questions (CQs), background questions (BQs) are new items for basic clinical knowledge, and future research questions (FRQs) are newly added clinically important items. Concerning the clinical treatment of liver cirrhosis, new findings have been reported over the past 5 years since the second edition. In this revision, we decided to match the international standards as much as possible by referring to the latest international guidelines. Newly developed agents for various complications have also made great progress. In comparison with the latest global guidelines, such as the European Association for the Study of the Liver (EASL) and American Association for the Study of Liver Diseases (AASLD), we are introducing data based on the evidence for clinical practice in Japan. The flowchart for nutrition therapy was reviewed to be useful for daily medical care by referring to overseas guidelines. We also explain several clinically important items that have recently received focus and were not mentioned in the last editions. This digest version describes the issues related to the management of liver cirrhosis and several complications in clinical practice. The content begins with a diagnostic algorithm, the revised flowchart for nutritional therapy, and refracted ascites, which are of great importance to patients with cirrhosis. In addition to the updated antiviral therapy for hepatitis B and C liver cirrhosis, the latest treatments for non-viral cirrhosis, such as alcoholic steatohepatitis/non-alcoholic steatohepatitis (ASH/NASH) and autoimmune-related cirrhosis, are also described. It also covers the latest evidence regarding the diagnosis and treatment of liver cirrhosis complications, namely gastrointestinal bleeding, ascites, hepatorenal syndrome and acute kidney injury, hepatic encephalopathy, portal thrombus, sarcopenia, muscle cramp, thrombocytopenia, pruritus, hepatopulmonary syndrome, portopulmonary hypertension, and vitamin D deficiency, including BQ, CQ and FRQ. Finally, this guideline covers prognosis prediction and liver transplantation, especially focusing on several new findings since the last version. Since this revision is a joint guideline by both societies, the same content is published simultaneously in the official English journal of JSGE and JSH.

Frailty in Nonalcoholic Fatty Liver Cirrhosis: A Comparison with Alcoholic Cirrhosis, Risk Patterns, and Impact on Prognosis

BACKGROUND

Physical frailty increases susceptibility to stressors and predicts adverse outcomes of cirrhosis. Data on disease course in different etiologies are scarce, so we aimed to compare the prevalence and risk factors of frailty and its impact on prognosis in nonalcoholic fatty liver (NAFLD) and alcoholic (ALD) cirrhosis. Patients and Methods. Cirrhosis registry RH7 operates since 2014 and includes hospitalized patients with decompensated cirrhosis, pre-LT evaluation, or curable hepatocellular carcinoma (HCC). From the RH7, we identified 280 ALD and 105 NAFLD patients with at least 6 months of follow-up.

RESULTS

Patients with NAFLD compared with ALD were older and had a higher proportion of females, higher body mass index (BMI) and mid-arm circumference (MAC), lower MELD score, CRP, and lower proportion of refractory ascites. The liver frailty index did not differ, and the prevalence of HCC was higher (17.1 vs. 6.8%, p=0.002). Age, sex, serum albumin, and C-reactive protein (CRP) were independent predictors of frailty. In NAFLD, frailty was also associated with BMI and MAC and in ALD, with the MELD score. The Cox model adjusted for age, sex, MELD, CRP, HCC, and LFI showed that NAFLD patients had higher all-cause mortality (HR = 1.88 95% CI 1.32-2.67, p < 0.001) and were more sensitive to the increase in LFI (HR = 1.51, 95% CI 1.05-2.2).

CONCLUSION

Patients with NAFLD cirrhosis had a comparable prevalence of frailty compared to ALD. Although prognostic indices showed less advanced disease, NAFLD patients were more sensitive to frailty, which reflected their higher overall disease burden and led to higher all-cause mortality.

Frailty as a predictive factor for survival after liver transplantation, especially for patients with MELD≤15-a prospective study

Introduction

Frailty has been discussed as a predictor of morbidity and mortality for liver cirrhosis. The aim of our study is to evaluate the role of frailty in liver transplantation, particularly for patients with MELD scores < 15.

Methods

All patients listed for liver transplantation between September 2015 and November 2018 were prospectively included in the study. Frailty was assessed by Fried’s frailty classification. Pre-, intra-, and postoperative data were prospectively recorded. Univariate and multivariate regression analyses were performed. The ethical approval of the institutional board review was obtained for the study.

Results

There were 114 patients included in the study, and their median MELD score was 16. Of these, 86 patients were defined as frail (75.4%). A total of 62 patients (54.4%) underwent liver transplantation, 11 (17.7%) died postoperatively, and 24 patients (21.0%) died while on the waitlist. All postoperative mortality cases were frail, and only 3 patients (12.5%) were non-frail in the waitlist mortality group. There were 14 patients who had MELD scores of <15 (58.3%). The overall survival of non-frail patients was significantly better than that of frail patients. The multivariate regression analyses identified frailty criteria, including unintended weight loss and low hand grip strength, and platelet count and being married or living in a solid partnership were prognostic factors for survival in all patients.

Conclusion

The addition of frailty assessment can be beneficial for predicting mortality after liver transplantation, especially in patients with low MELD score. Frail patients on the waitlist have significant risk for mortality even with low MELD score.

Physical Function Measured Prior to Lung Transplantation Is Associated With Posttransplant Patient Outcomes

INTRODUCTION

The primary objective of this study was to determine whether pretransplant physical function is correlated with posttransplantation outcomes.

METHODS

We performed a retrospective study of patients that participated in pretransplantation screening and subsequently underwent lung transplantation. Pretransplant variables of interest included demographics, muscle mass, body composition, physical function, and physical frailty. Correlation tests were performed to assess relationships with significance set at 0.05.

RESULTS

Twenty-five patients with a mean age of 57 ± 13 years (68% male) with pretransplant lung allocation score of 45 ± 14 were included. This cohort had a 3-year mortality rate of 32% (n = 8). Pretransplant 4-m gait speed was significantly related to performance on the Short Physical Performance Battery (r = 0.74, P = .02) and distance ambulated on the 6-minute walk test (r = 0.62, P = .07) at hospital discharge. Older age was associated with slower gait speed and worse performance on sit-to-stand testing at hospital discharge (r = -0.76, P = .01 and r = -0.75, P = .01, respectively). Statistically, only diagnosis of cystic fibrosis was associated with 3-year mortality.

DISCUSSION

Our study demonstrates that demographic, clinical, and physical function assessed prior to lung transplantation may be indicators of functional recovery.

Exercise interventions in solid organ transplant candidates: A systematic review

INTRODUCTION

Exercise training may be recommended to solid organ transplant (SOT) candidates to improve fitness and tolerance before surgery. We aimed to determine the acceptance, safety, and effectiveness of exercise interventions in SOT candidates.

METHODS

Online databases were searched. Studies of any design were included. Outcomes of interest were acceptance, safety, exercise capacity, and health-related quality of life.

RESULTS

Twenty-three articles were included. Acceptance ranged from 16% to 100%. In the fifteen studies that assessed adverse events, none mentioned any adverse events occurring during the study. Five out of seven studies reported an increase in maximal exercise capacity post-exercise in the intervention group (range of mean change: 0.45 to 2.9 mL/kg). Eight out of fourteen studies reported an increase in 6-minute walking distance in the intervention group after the training period (range of mean change: 40-105 m). Two articles showed an improvement in the mental composite scores as well as in the physical composite scores post-exercise in the intervention group.

CONCLUSION

There was a lack of significant findings among most randomized controlled trials. Exercise training is acceptable and safe for selective SOT candidates. The effects of exercise training on exercise capacity and quality of life in SOT candidates are unclear.

Frailty assessment and postoperative outcomes among patients undergoing general surgery

BACKGROUND

Frailty is an emerging concept in modern general surgery because of its correlation with adverse outcomes. More frail older patients are undergoing general surgery due to the rapid aging of the population and the effect of the "baby boom" generation. However, there is no consensus on the definition of frailty and on ways to assess its severity and effect.

PURPOSE

To describe the definition and epidemiology, measurement tools, and the effect of frailty on postoperative outcomes after general surgery.

METHODS

PubMed and Google Scholar databases were comprehensively searched.

RESULTS

Frailty is a syndrome defined as increased vulnerability to stressors due to a decline in physiological function and reserve among organ systems, resulting in adverse outcomes. Numerous tools have been described and tested for frailty measurement, but the ideal clinical tool has not been found yet. The evidence from cohort studies and meta-analyses shows associations between preoperative frailty and adverse perioperative outcomes after general surgery.

CONCLUSION

Frailty is an essential concept in general surgery. However, further studies have to identify the optimal way to preoperatively assess frailty and risk-stratify older patients.

Characteristics of sarcopenia by European consensuses and a phenotype score

BACKGROUND

We aimed to assess the clinical characteristics of sarcopenia by the original and revised European Working Group on Sarcopenia in Older People (EWGSOP 1 and 2), and to propose a new sarcopenia phenotype score (SPS) to improve relevance of clinical outcomes.

METHODS

Analyses were performed in 1408 older adults of the Aging Study of PyeongChang Rural Area, a community-based cohort in Korea. For sarcopenia definitions, we used EWGSOP 1, EWGSOP 2, and SPS, a new index counting number of abnormal domains among components of grip strength, gait speed, or muscle mass. Frailty status by the frailty index and the Cardiovascular Health Study frailty score was compared with sarcopenia measures. Prediction ability for composite outcome combining death and institutionalization due to functional decline was assessed among sarcopenia measures.

RESULTS

Generally, sarcopenia spectrum by both EWGSOP 1 and 2 was associated with worse functional status in parameters of geriatric assessments. However, population who were considered as sarcopenic by EWGSOP 1, but not by EWGSOP 2, showed increased risk of composite outcome and worse frailty status, compared with people who were classified as not sarcopenic by both EWGSOP 1 and 2. With SPS, dose-response relationship was observed with both frailty status and outcome prediction. Prediction for composite outcome was better in SPS than in EWGSOP 2 classification.

CONCLUSIONS

A new SPS might be used to classify sarcopenic burden in older adults to resolve possible inconsistencies in phenotype correlation and outcome prediction of EWGSOP 2 criteria.

Posttransplant Outcome of Lean Compared With Obese Nonalcoholic Steatohepatitis in the United States: The Obesity Paradox

Morbid obesity is considered a relative contraindication for liver transplantation (LT). We investigated if body mass index (BMI; lean versus obese) is a risk factor for post-LT graft and overall survival in nonalcoholic steatohepatitis (NASH) and non-NASH patients. Using the United Network for Organ Sharing (UNOS) database, LT recipients from January 2002 to June 2013 (age ≥18 years) with follow-up until 2017 were included. The association of BMI categories calculated at LT with graft and overall survival after LT were examined. After adjusting for confounders, all obesity cohorts (overweight and class 1, class 2, and class 3 obesity) among LT recipients for NASH had significantly reduced risk of graft and patient loss at 10 years of follow-up compared with the lean BMI cohort. In contrast, the non-NASH group of LT recipients had no increased risk for graft and patient loss for overweight, class 1, and class 2 obesity groups but had significantly increased risk for graft (P < 0.001) and patient loss (P = 0.005) in the class 3 obesity group. In this retrospective analysis of the UNOS database, adult recipients selected for first LT and NASH patients with the lowest BMI have the worse longterm graft and patient survival as opposed to non-NASH patients where the survival was worse with higher BMI.

Sarcopenia in Cirrhosis: Fallout on Liver Transplantation

BACKGROUND

Liver transplantation (LT) is a game changer in cirrhosis. Poor muscle mass defined as sarcopenia may potentially upset the LT scoreboard.

AIM

To assess the prevalence and impact of sarcopenia on the intraoperative and early postoperative outcomes in Indian patients undergoing LT.

METHODS

Pre LT, single-slice routine computed tomography images at L3 vertebra of 115 LT recipients were analyzed, to obtain cross-sectional area of six skeletal muscles normalized for height in m² - skeletal muscle index (SMI; cm²/m²). SMI< 52.4 in males and <38.5 in females was called sarcopenia. The intraoperative, postoperative outcome parameters and 90-day mortality were compared between sarcopenics and nonsarcopenics.

RESULTS

Sarcopenia was found in 47.8% of patients [M (90.4%); age, 46.3 ± 10; BMI, 24.5 ± 4.3 kg/m2; child A:B:C = 1%:22%:77%; MELD, 20.6 ± 6.3; etiology alcohol: nonalchohol = 53%:47%; Charlson Comorbidity Index (CCI) > 3:≤3 = 56.5%:43.5%]. Sarcopenics vs. Nonsarcopenics; early postoperative complications: [sepsis, 49(89%) vs. 33(55%), P = 0.001; neurologic complications, 16(29.6%) vs. 5(8.8%), P = 0.040; Clavien-Dindo Classification ≥3-24 (43.6%):15 (25.4%),P = 0.041; ancillary parameters (days), duration of ventilation [median (range)] 1.5(1-3) vs. 1 (1-2), P = 0.021; intensive care unit (ICU) stay 12 (8-16) vs. 10 (8-12), P = 0.024; time to ambulation 9 (7-11) vs. 6 (5-7), P = 0.001; drain removal 18.7 ± 7.3 vs. 14.4 ± 6.2, P = 0.001; need for tracheostomy 5 (9%) vs. 0 (%), P = 0.017; preoperative prevalence of acute kidney injury, comorbidities and requirement for dialysis, intraoperative blood loss & inotropic support were significantly higher in sarcopenics. Ninety-day mortality was comparable between sarcopenics 5 (9.09%) and nonsarcopenics 4 (6.6%) P = 0.63. SMI (OR: 0.83; 95% CI: 0.71-0.97, P = 0.016; Acute on chronic liver failure (ACLF) presentation 12.5 (1.65-95.2), P = 0.015 and intraoperative blood loss 3.74 (0.96-14.6), P = 0.046 were predictors of 90-day mortality.

CONCLUSION

Almost 50% of LT recipients had sarcopenia, who had a higher incidence of postoperative sepsis, neurological complications, longer ICU stay and ventilatory support. Low SMI, ACLF presentation, and intraoperative blood loss were the independent predictors of early mortality.

Liver Transplantation for Nonalcoholic Steatohepatitis: Pathophysiology of Recurrence and Clinical Challenges

Nonalcoholic steatohepatitis is the fastest-growing indication for the liver transplant and a leading cause of hepatocellular carcinoma among patients listed for liver transplantation in the USA. Post-transplant nonalcoholic hepatic steatosis and steatohepatitis are frequent complications of liver transplantation. Nonalcoholic steatohepatitis poses a significant challenge in both pre- and post-transplant period due to its association with metabolic syndrome, coronary artery disease, chronic kidney disease, and obstructive sleep apnea. While optimal therapy is not yet available in the post-liver transplant setting, lifestyle interventions continue to remain as the mainstay of therapy for post-transplant nonalcoholic steatohepatitis. Early recognition with protocol biopsies and noninvasive modalities, along with modification of known risk factors, are the most effective methods to curtail the progression of nonalcoholic steatohepatitis in the absence of FDA-approved pharmacologic therapy.

Quantification of muscle mass in the legs of patients with peripheral arterial occlusive disease: associations between volumetric and cross-sectional single-slice measurements for identification of atrophy and focal sarcopenia

BACKGROUND

Sarcopenia, commonly determined by measuring skeletal muscle mass index (SMI) at the third lumbar level, has been identified as a predictor of clinical outcome in a variety of diseases. For patients with peripheral arterial occlusive disease (PAOD), we hypothesized that lower extremity SMI (LESMI) might be a more precise predictor of outcome and the extent of chronic ischemia than the systemic muscle mass at the L3 level. We investigated the association between complete muscle volume and muscle area derived with single-slice 2-dimensional measurements in the legs to identify at which level cross-sectional single-slice measurements are most representative of the muscle volume and investigated whether LESMI is associated with systemic sarcopenia and PAOD severity.

METHODS

Muscle volumes and areas were semiautomatically segmented from computed tomography (CT) scans of the affected and contralateral legs of 50 PAOD patients with Fontaine stage IIb and 50 PAOD patients with Fontaine stage IV. The muscle mass was determined for the complete volumes of the upper and lower legs and for cross-sectional slices at 40%, 50%, and 60% of the length of the femur and tibia. Patients were determined as sarcopenic based on sex-specific cut-off values at the L3 spinal segment. Two observers segmented 20 randomly selected patients to determine the interobserver reliability with the intraclass correlation coefficient.

RESULTS

The correlation between the LESMI of the complete muscle volume and the three cross-sectional slices in all 200 upper and 200 lower legs was moderately strong to strong. Interobserver reliability of cross-sectional slice segmentation was excellent. The LESMI, both measured volumetrically and cross-sectionally, were significantly lower in patients with sarcopenia compared to patients without sarcopenia. The LESMI was lower in patients with Fontaine stage IV compared to patients with Fontaine stage IIb for both volumetric and cross-sectional measurements.

CONCLUSIONS

Segmentation of skeletal muscle mass from cross-sectional single-slice CT in the upper and lower leg can accurately and precisely substitute complete volume segmentations. These findings warrant the use of measurements based on cross-sectional single-slice CT for assessing the LESMI. Patients with systemic sarcopenia are also at increased risk for muscle mass loss in the lower extremities. In the current study, LESMI was lower in patients with Fontaine class IV PAOD compared to patients with Fontaine class IIb PAOD. Future studies should assess the predictive value of the LESMI on clinical outcomes in PAOD patients.

Frailty: implications for clinical practice and public health

Frailty is an emerging global health burden, with major implications for clinical practice and public health. The prevalence of frailty is expected to rise alongside rapid growth in the ageing population. The course of frailty is characterised by a decline in functioning across multiple physiological systems, accompanied by an increased vulnerability to stressors. Having frailty places a person at increased risk of adverse outcomes, including falls, hospitalisation, and mortality. Studies have shown a clear pattern of increased health-care costs and use associated with frailty. All older adults are at risk of developing frailty, although risk levels are substantially higher among those with comorbidities, low socioeconomic position, poor diet, and sedentary lifestyles. Lifestyle and clinical risk factors are potentially modifiable by specific interventions and preventive actions. The concept of frailty is increasingly being used in primary, acute, and specialist care. However, despite efforts over the past three decades, agreement on a standard instrument to identify frailty has not yet been achieved. In this Series paper, we provide an overview of the global impact and burden of frailty, the usefulness of the frailty concept in clinical practice, potential targets for frailty prevention, and directions that need to be explored in the future.

Analysis of pre- and intraoperative clinical for successful operating room extubation after living donor liver transplantation: a retrospective observational cohort study

BACKGROUND

Early extubation after liver transplantation is safe and accelerates patient recovery. Patients with end-stage liver disease undergo sarcopenic changes, and sarcopenia is associated with postoperative morbidity and mortality. We investigated the impact of core muscle mass on the feasibility of immediate extubation in the operating room (OR) after living donor liver transplantation (LDLT).

METHODS

A total of 295 male adult LDLT patients were retrospectively reviewed between January 2011 and December 2017. In total, 40 patients were excluded due to emergency surgery or severe encephalopathy. A total of 255 male LDLT patients were analyzed in this study. According to the OR extubation criteria, the study population was classified into immediate and conventional extubation groups (39.6 vs. 60.4%). Psoas muscle area was estimated using abdominal computed tomography and normalized by height squared (psoas muscle index [PMI]).

RESULTS

There were no significant differences in OR extubation rates among the five attending transplant anesthesiologists. The preoperative PMI correlated with respiratory performance. The preoperative PMI was higher in the immediate extubation group than in the conventional extubation group. Potentially significant perioperative factors in the univariate analysis were entered into a multivariate analysis, in which preoperative PMI and intraoperative factors (i.e., continuous renal replacement therapy, significant post-reperfusion syndrome, and fresh frozen plasma transfusion) were associated with OR extubation. The duration of ventilator support and length of intensive care unit stay were shorter in the immediate extubation group than in the conventional extubation group, and the incidence of pneumonia and early allograft dysfunction were also lower in the immediate extubation group.

CONCLUSIONS

Our study could improve the accuracy of predictions concerning immediate post-transplant extubation in the OR by introducing preoperative PMI into predictive models for patients who underwent elective LDLT.

Predictive Capacity of Risk Models in Liver Transplantation

Supplemental Digital Content is available in the text.

Several risk models to predict outcome after liver transplantation (LT) have been developed in the last decade. This study compares the predictive performance of 7 risk models.

Serum Zinc Concentration and Sarcopenia: A Close Linkage in Chronic Liver Diseases

We sought to investigate the influence of serum zinc (Zn) concentration on sarcopenia in chronic liver diseases (CLDs, n = 372, median age = 65 years, 147 liver cirrhosis (LC) cases (39.5%)). Sarcopenia was defined by low grip strength and low skeletal muscle mass. Study subjects were divided into the following three groups (High-, Intermediate-, and Low-Zn groups) based on the baseline serum Zn level. The impacts of serum Zn concentration on sarcopenia were examined. The median (interquartile range) serum Zn concentration for all cases was 72.85 (63.7, 81.45) μg/dL. The proportions of sarcopenia in the High-Zn, Intermediate-Zn, and Low-Zn groups were 10.75% (10/93), 11.23% (21/187), and 27.17% (25/92), respectively (P = 0.9046 (High vs. Intermediate), P = 0.0007 (Intermediate vs. Low), P = 0.0044 (High vs. Low), overall P value = 0.0009). The median serum Zn concentrations in patients with sarcopenia, pre-sarcopenia, and control were 66.35, 73.1 and 73.8 μg/dL, respectively (P = 0.0234 (sarcopenia vs. pre-sarcopenia), P = 0.2116 (pre-sarcopenia vs. control), P = 0.0002 (sarcopenia vs. control), overall P value = 0.0016). In the multivariate analyses of factors linked to the presence of sarcopenia, Low-Zn was an independent predictor for all cases (P = 0.0236) and LC cases (P = 0.0082). In conclusion, Zn deficiency can be an independent predictor for sarcopenia in patients with CLDs.

Recent Progress in Sarcopenia Research: a Focus on Operationalizing a Definition of Sarcopenia

PURPOSE OF REVIEW

To discuss recent progress in sarcopenia research and to highlight controversies in the field particularly around reaching consensus on a definition of sarcopenia.

RECENT FINDINGS

Accordingly, this review begins with a discussion of the increasing awareness of this condition; briefly describes evolving definitions of sarcopenia; suggests a framework for consistent terminology for sarcopenia; discusses outstanding issues in the definition of sarcopenia; and reviews the association between sarcopenia and adverse outcome in older adults. In addition, the role of sarcopenia in other diseases is discussed. The field of sarcopenia continues to hold considerable promise and work continues to resolve outstanding concerns in this field with a unifying consensus definition on the horizon.