Role of nutritional status and nutritional support in outcome of hepatitis B virus-associated acute-on-chronic liver failure

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Acute-on-Chronic Liver Failure: Steps Towards Consensus

Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized by organ failure and high short-term mortality. Since its first definition in 2013, many international organizations have defined this syndrome and, till now, there has been no agreement regarding definitions and diagnostic criteria. Although the precise mechanism of ACLF is unknown, precipitant factors and the systemic inflammation response play a major role. Specific management of this high-mortality syndrome is still under development, but a general consensus in the diagnosis and management of ACLF is needed.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Outpatient Intensive Nutrition Therapy Improves Survival and Frailty in Males With Alcohol-related ACLF - Randomized Controlled Trial

BACKGROUND & AIMS

Improvement in the nutritional status of patients with acute-on-chronic liver failure (ACLF) may lead to reduction in morbidity and mortality. This study assessed the impact of dietician-supported outpatient intensive nutrition therapy (OINT) on survival and frailty in patients with alcohol-related ACLF METHODS: Seventy patients with alcohol-related ACLF (Asia Pacific Association for the Study of the Liver [APASL] criteria) and frailty were randomized 1:1 to receive standard medical therapy (SMT) plus OINT (intervention) vs SMT (control) alone. The primary outcome was an improvement in survival at 3 months. Secondary outcome measures included improvement in frailty, prognostic scores, and hospitalization.

RESULTS

There was a significant improvement in overall survival in the OINT group as compared with the SMT group after 3 months of follow up (91.4% [standard error (SE), 4.7%] vs 57.1% [SE, 8.4%]; P < .00). On Cox regression model, inclusion in the intervention arm, baseline skeletal muscle index (SMI), and APASL ACLF Research Consortium (AARC score) were independent predictors of survival (P < .05). The liver frailty index (LFI) score also significantly improved in the OINT as compared with SMT (Δ-0.93; 95% confidence interval, -0.71 to 1.13 vs Δ -0.33; 95% confidence interval, -0.44 to 0.72; P < .00). The disease severity including MELD, MELD-Na, and AARC score showed a significant improvement in the OINT group as compared with the SMT group (P < .05). The patients in OINT group had lesser number of hospitalizations 6 (17%) vs 16 (45.7%) (P = .01) as compared with the SMT group.

CONCLUSION

Outpatient intensive nutrition therapy significantly improves survival, frailty, and disease severity with a reduction in number of hospitalizations and supports the key role of nutrition in treatment of patients with alcohol-related ACLF.

CLINICAL TRIAL REGISTRY NUMBER

ctri.nic.in/ CTRI/2022/01/039735.

The Influence of Piper sarmentosum Extract on Growth Performance, Intestinal Barrier Function, and Metabolism of Growing Chickens

In the poultry industry, there is an urgent need to evaluate and introduce natural, effective, and safe alternatives for synthetic antibiotics, which have been banned in most countries. The present study aimed to investigate the effects of dietary supplementation with Piper sarmentosum extract (PSE) on the growth performance, intestinal barrier function, and metabolism of growing chickens. A total of 400 seven-day-old female chicks were randomly assigned to four dietary treatments, each of which consisted of five replicates and twenty birds each. The four experimental treatments were fed a basal diet containing 0, 100, 200, and 300 mg PSE/kg (BC, PSE1, PSE2, and PSE3 groups), respectively. The experiment lasted for 28 days. The results showed that dietary supplementation with PSE had no significant effects on the final body weight, average daily gain (ADG), average daily feed intake (ADFI), and the ratio of ADFI to ADG (F/G) (p > 0.05). Compared with the BC group, dietary supplementation with 200-300 mg/kg PSE increased the villus height in the jejunum and ileum of chickens (p < 0.05). The PSE-treated groups significantly increased the mRNA expression of Occludin, ZO-1, and Claudin-1 in the ileal mucosa of chickens (p < 0.05). In addition, a significant decrease in ileal TNF-α and IL-8 mRNA expression (p < 0.05) and a significant increase in IL-22 (p < 0.05) were observed in the PSE2 treatment compared to the BC group. Additionally, three gut metabolites (i.e., citrate, isocitrate, and spermine) showed significant differences among treatments (p < 0.05) and were involved in the tricarboxylic acid (TCA) cycle, the transfer of acetyl groups into mitochondria, and spermidine and spermine biosynthesis, respectively. In conclusion, the findings obtained here indicate that supplemental PSE can enhance the anti-inflammatory capacity and intestinal mucosal barrier function of chickens.

Prealbumin as a Predictor of Short-Term Prognosis in Patients with HBV-Related Acute-on-Chronic Liver Failure

Purpose

Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is a serious medical condition with a high short-term mortality rate, making accurate prognostic assessment essential for informed clinical decision-making. In this study, we aimed to develop a simple and effective prognostic model for predicting short-term mortality in patients with HBV-ACLF.

Patients and Methods

To achieve our objective, we enrolled both a cross-sectional cohort (n = 291) and a retrospective cohort (n = 185) in this study. We collected laboratory and clinical data from these cohorts and performed univariate and multivariate logistic regression analyses to identify independent predictors of short-term mortality. Subsequently, we developed a novel prognostic score for HBV-ACLF, which was validated and assessed using receiver operating characteristic (ROC) curve analysis to determine its performance.

Results

Our analysis revealed that the admission prealbumin (PAB) level was a robust independent predictor of 30-day mortality, with an area under the receiver operating characteristic (AUROC) of 0.760. Moreover, we developed the HIAPP score, a prognostic-score model based on PAB. The HIAPP score was significantly lower in survivors compared to non-survivors (-2.80±0.21 vs 0.97±0.41, P < 0.001). The HIAPP score's AUROC value was 0.899, which was found to be superior to the MELD score (AUROC = 0.795) and the CLIF-C ACLF score (AUC =0.781) and comparable to the COSSH-ACLF II score (AUC =0.825) for predicting 30-day mortality. These findings were also validated in a separate cohort, further supporting the utility of the HIAPP score as a prognostic tool for HBV-ACLF patients.

Conclusion

Our study identifies the admission PAB level as a simple and valuable predictive index for 30-day mortality in HBV-ACLF patients. Furthermore, the HIAPP score, which incorporates PAB, PLT, INR, HE, and age, is an easy-to-use and pragmatic prognostic score in predicting short-term mortality.

Fat rather than health - Ecotoxic responses of Bufo raddei to environmental heavy metal stress during the non-breeding season

The non-breeding season is a critical period for iteroparous animals to repair damage and store energy, which is crucial for future survival and reproductive success. However, it is unknown how animals allocate energy efficiently among reproduction, self-maintenance, and repair of oxidative damage caused by breeding during the non-breeding period, particularly under pollution. In the present study, the self-maintenance response and reproductive strategy of Bufo raddei to long-term environmental heavy metal stress was explored during the non-breeding season. Heavy metal enrichment level, organ coefficients, nutritional status, gonadal developmental level, oxidation level, and the immune status of B. raddei during the non-breeding season were tested, energy allocation preferences and energy consumption costs were analyzed. The results revealed significant heavy metal accumulation through biomagnification in the organs of B. raddei from the polluted area. Under long-term environmental heavy metal pollution, the energy investment by B. raddei for growth and energy storage was higher than that for health-maintenance during the early life cycle stage. The energy inputted for immune and antioxidant functions was significantly lower, and the energy inputted for self-maintenance during the early life stage was significantly higher than that during the late stage. B. raddei from a heavy metal polluted area spent more energy consumption cost on immunity and oxidative stress, but suffered higher oxidative stress and lower immune status. Moreover, the reproductive input of individuals in a heavy metal polluted area was generally low during the non-breeding season, and the energy input for reproduction limited the energy input for self-maintenance in females.

Low T3 syndrome is associated with poor prognosis in patients with hepatitis B virus-related acute-on-chronic liver failure

BACKGROUND

Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is a critical disease with high mortality risk. Low triiodothyronine syndrome (LT3S) is associated with various severe acute and chronic diseases. We investigated the relationship between LT3S and poor prognosis in patients with HBV-ACLF.

RESEARCH DESIGN AND METHODS

A total of 198 patients with HBV-ACLF were enrolled between January 2018 and March 2019. We screened for independent risk factors for 28-day mortality using univariate and multivariate logistic regression analyses. Spearman's correlation analysis was used to evaluate the correlation between LT3S and the poor prognostic parameters of HBV-ACLF.

RESULTS

LT3S was an independent risk factor for 28-day mortality in HBV-ACLF patients (odds ratio: 4.035, 95% confidence interval 1.117-14.579; p = 0.033). The death group had a lower serum FT3 level (Z-value = 2639.000, p < 0.001). Serum FT3 levels were negatively correlated with age, C-reactive protein, international normalized ratio, and neutrophil count but positively correlated with lymphocyte count. A negative correlation between FT3 and various prognostic scores was observed, indicating that a low FT3 level was closely related to a poor prognosis.

CONCLUSIONS

LT3S was an independent risk factor for 28-day mortality and was correlated with poor prognosis in patients with HBV-ACLF.

[Clinical Value of Cystatin C-Based Estimated Glomerular Filtration Rate in Assessing Short-Term Mortality in Patients with Hepatitis B Virus-Related Acute-on-Chronic Liver Failure Treated with Artificial Liver Support System]

OBJECTIVE

To evaluate the predictive value of using cystatin c-based estimated glomerular filtration rate (eGFR-CysC) in assessing the prognosis of hepatitis B virus-associated acute-on-chronic liver failure (HBV-ACLF) patients treated with artificial liver support system (ALSS).

METHODS

A total of 364 HBV-ACLF inpatients treated with ALSS at our hospital were enrolled retrospectively in the study. The patients were divided into the survival group ( n=269) and non-survival group ( n=95) according to mortality within 28 d, and their clinical information and laboratory data were analyzed for assessing short-term prognostic values.

RESULTS

Multivariate Cox regression analysis identified eGFR-CysC as one of the independent risk factors associated with mortality within 28 days in HBV-ACLF patients (the hazard ratio=0.987; 95% confidence interval, 0.979-0.996, P=0.003). In addition, baseline eGFR-CysC was negatively correlated with the model for end-stage liver disease (MELD) score ( r=-0.439, P<0.001), MELD plus sodium (MELD-Na) score ( r=-0.481, P<0.001) and Chronic Liver Failure Consortium ACLF (CLIF-C ACLF) score ( r=-0.340, P<0.001). Receiver operating characteristic (ROC) curve analysis showed area under the curve ( AUC) of eGFR-CysC were 0.639, 0.697, 0.716, 0.749 and the best cut-off value were 70.620, 67.525, 61.725, 64.685 mL/(min·1.73 m 2), respectively, for baseline value and the first, second, and third treatment with ALSS.

CONCLUSION

eGFR-CysC could be used to assist clinical assessment of short-term mortality in HBV-ACLF patients treated with ALSS, and has better clinical application value for dynamic monitoring.

Malnutrition in Patients with Liver Cirrhosis

Liver cirrhosis is an increasing public health threat worldwide. Malnutrition is a serious complication of cirrhosis and is associated with worse outcomes. With this review, we aim to describe the prevalence of malnutrition, pathophysiological mechanisms, diagnostic tools and therapeutic targets to treat malnutrition. Malnutrition is frequently underdiagnosed and occurs-depending on the screening methods used and patient populations studied-in 5-92% of patients. Decreased energy and protein intake, inflammation, malabsorption, altered nutrient metabolism, hypermetabolism, hormonal disturbances and gut microbiome dysbiosis can contribute to malnutrition. The stepwise diagnostic approach includes a rapid prescreen, the use of a specific screening tool, such as the Royal Free Hospital Nutritional Prioritizing Tool and a nutritional assessment by dieticians. General dietary measures-especially the timing of meals-oral nutritional supplements, micronutrient supplementation and the role of amino acids are discussed. In summary malnutrition in cirrhosis is common and needs more attention by health care professionals involved in the care of patients with cirrhosis. Screening and assessment for malnutrition should be carried out regularly in cirrhotic patients, ideally by a multidisciplinary team. Further research is needed to better clarify pathogenic mechanisms such as the role of the gut-liver-axis and to develop targeted therapeutic strategies.