Introduction

Cirrhosis is a chronic liver disease that, due to its natural progression and complications, affects the quality of life (QOL). Tunisian data related to the QOL of cirrhotic patients are limited. Our objectives were to evaluate the QOL of cirrhotic patients and identify factors influencing it.

Aims & Methods

We conducted a cross-sectional study, including cirrhotic patients followed in our outpatient clinic. QOL was assessed using the following questionnaires: Chronic liver disease questionnaire (CLDQ) (QOL impairment threshold defined at five), 36-item short form (SF-36), The Hospital anxiety and depression scale , the Clinical frailty scale , the fatigue severity scale , the Insomnia severity index , and the Work productivity and activity impairment index .
Patient data regarding medical history, cirrhosis characteristics, and socio-economic conditions were collected.
Statistical analysis was performed using the SPSS software (significance threshold p=0.05).

Results

One hundred (56 women and 44 men) were included, with an average age of 60.62 years. The cirrhosis was due to viral hepatitis in 55% of cases with a CHILD-PUGH score classified as B or C (49 cases). Thirty-four patients had a history of upper gastro-intestinal bleeding. Thirty patients presented with ascites.
The mean SF-36 was 54.06, and the mean CLDQ was 4.7. Twenty-five patients experienced anxiety, and 35 had depression, 22 suffered from clinically patent insomnia.
In multivariate analysis . The factors identified as influencing the SF-36 were the education level (p=0.014), the CHILD-PUGH score (p=0.016), the presence of esophageal varices (p=0.016) or ascites (p=0.012), anemia (p=0.016), and low serum albumin levels (p=0.014).
The factors influencing CLDQ were the CHILD-PUGH score (p=0.020), the presence of ascites (p=0.012), anemia (p=O.025), and low serum albumin levels (p=0.018).
A CLDQ below five was associated with a CHILD-PUGH score B or C (p=0.012), the presence of ascites (p=0.011), a portal vein thrombosis (=0.048), and low serum albumin levels (p=0.010).

Conclusion

The results of our study highlight the importance of assessing QOL during cirrhosis and developing comprehensive care for our patients

Introduction

Frailty is a complex clinical syndrome characterized by a reduction in physiological reserves and an increased vulnerability to stressors. Although it is often associated with aging, frailty also affects younger populations, particularly patients with severe chronic illnesses such as cirrhosis.
The objective of our study was to assess the prevalence of frailty among cirrhotic patients in a Tunisian population and to identify associated risk factors.

Aims & Methods

An analytical cross-sectional study was conducted over a three-month period in the gastroenterology department of Sahloul University Hospital in Sousse. Patients aged 18 to 70 years, diagnosed with cirrhosis (based on clinical, biological, morphological, endoscopic, and/or histological criteria) were included. Patients with severe chronic diseases that could overestimate frailty or with osteoarticular diseases limiting mobility were excluded.
Frailty was assessed using the Clinical Frailty Scale (CFS) for global frailty (GF) and the Short Physical Performance Battery (SPPB) for physical frailty (PF).

Results

A total of 50 patients were included. The median age was 59 ± 9.2 years, with a male-to-female ratio of 1.5. The main etiologies of cirrhosis were metabolic liver disease (38%) and hepatitis B-related cirrhosis (28%). According to the Child-Pugh score, 39% of patients were classified as Child A, 36% as Child B, and 26% as Child C, with an average MELD score of 14.2 ± 5.9.
Regarding frailty, 42% of patients exhibited GF and 46% had PF.
Univariate analysis revealed several factors significantly associated with GF, namely: female gender (p=0.035), age >60 years (p=0.02), presence of grade I hepatic encephalopathy (p=0.038), presence of ascites (p<0.001), BMI < 18.5 kg/m² (p=0.037), sedentary lifestyle (p<0.001), MELD score >15 (p=0.001), and Child-Pugh score B-C (p=0.003).
For PF, similar results were observed: age >60 years (p=0.03), presence of ascites (p<0.001), sedentary lifestyle (p=0.009), and MELD score >15 (p=0.001).
Multivariate analysis identified independent risk factors associated with both GF and PF as: age >60 years, presence of ascites, and a MELD score >15.

Conclusion

This study highlights the high prevalence of frailty among cirrhotic patients, emphasizing the importance of systematic assessment of this condition in clinical practice. Age, ascites, and the severity of cirrhosis were found to be significant indicators of frailty. These findings suggest the need to implement targeted rehabilitation programs to improve physical function and quality of life in this patient population.

Introduction

Liver cirrhosis is characterized by microbial dysbiosis, intestinal inflammation and a weakened gut barrier and associated with an increased risk of complications. We previously observed a positive influence of L-ornithine-L-aspartate (LOLA) on gut microbiome composition in cirrhosis (1). The current study aimed to investigate the effect of LOLA on microbiome dysbiosis, quality of life, sarcopenia, intestinal permeability, inflammation and metabolite composition.

Aims & Methods

In this monocentric, open-label, phase 4 study, LOLA (18g/day) was administered orally for three months to liver cirrhosis patients with hepatic encephalopathy grades (0-2). We investigated changes in their gut microbiome composition (16s rRNA sequencing, alpha and beta diversity, differential abundance), quality of life (SF36), blood ammonia concentrations, measurements of sarcopenia and frailty (appendicular lean muscle mass, anthropometric measures, liver frailty index, SARC-F), biomarkers of gut permeability, inflammation and sarcopenia as well as metabolic alterations in stool, serum, and urine.

Results

65 patients were enrolled, and 52 patients completed the 3-month study (40.4% female, age 62 (58; 65)). While LOLA reduced the abundance of the genus Romboutsia, it did not significantly change overall microbiome diversity. LOLA led to a significant improvement in the vitality dimension of the SF36 questionnaire (45 (35; 60) to 50 (45; 60), p=0.019) and decreased plasma ammonia levels in patients with elevated baseline ammonia (69.5 (54; 225) to 46.0 (22; 66) µmol/L, p=0.004) Although muscle mass generally declined across the study, this was not observed in patients whose elevated ammonia levels improved. Sarcopenia and frailty scores and the muscle biomarkers myostatin, irisin, fibroblast growth factor 21, insulin-like growth factor 1 were unaffected by LOLA treatment. Diamine oxidase, a marker of gut barrier dysfunction, significantly decreased (from 12.75 U/mL (11.25; 17.45) to 11.15 U/mL (9.9; 15.65), p=0.016), while LPS binding protein, a marker of innate immune response to bacterial translocation, significantly increased (from 17.05 µg/mg (14.7; 19.8) to 17.39 µg/mg (16.2; 21.9), p=0.006). Calprotectin, zonulin and sCD14 did not show significant changes. Metabolomic analysis revealed an increase in serum alanine levels (pFDR=0.014) with additional subtle shifts in lipoprotein and amino acid profiles.

Conclusion

In summary, LOLA was associated with an improvement in vitality, an important patient-reported outcome accompanied by alterations in gut microbial composition and prevented muscle loss in patients with hyperammonaemia. Furthermore, LOLA was associated with improvements in gut permeability and endotoxin handling. The slight increase in alanine observed in the metabolomics analysis may be a consequence of LOLA metabolism. LOLA may be a valuable supportive treatment for enhancing quality of life in cirrhosis by targeting the gut liver axis and may be particularly beneficial in preventing muscle loss in patients with hyperammonaemia.

References

1. Horvath A, Traub J, Aliwa B, Bourgeois B, Madl T, Stadlbauer V. Oral Intake of L-Ornithine-L-Aspartate Is Associated with Distinct Microbiome and Metabolome Changes in Cirrhosis. Nutrients. 2022 Feb 10;14(4):748.

Introduction

Cirrhosis is characterized by structural and functional hepatic alterations. The associated metabolic imbalances and psycho-neurological factors contribute to the high prevalence of sexual disorders and erectile dysfunction among affected patients. The aim of our study was to identify factors associated with sexual dysfunction in cirrhotic patients.

Aims & Methods

We conducted a prospective cross-sectional study, collecting data from patients followed for cirrhosis at the gastroenterology department of Charles Nicolle Hospital in Tunis over a one-year period. Female sexual function was assessed using the FSFI questionnaire. Female sexual dysfunction was defined by an FSFI score below 26 (or below 20 in post menopausal women). Male sexual function was evaluated using the IIEF-15 questionnaire. Male sexual dysfunction was identified by an IIEF-15 score below 42.9. Erectile dysfunction was confirmed by an IIEF-5 score
below 26. An analytical statistical study was conducted, highlighting factors associated with sexual dysfunction in both female and male patient groups.

Results

We included 55 cirrhotic patients (24 women and 31 men), with a sex ratio (M/F) of 1.29 and a mean age at inclusion of 59.11 ± 12.16 years. Female sexual dysfunction was observed in 70.8% of female patients. Male sexual dysfunction was found in 61.3% of patients. Erectile dysfunction was reported in 74.1% of men. Our study showed that the factors associated with female sexual dysfunction were: low economic status (p = 0.007), the presence of arterial hypertension (p = 0.026), and hepatic disease severity attested by Child-Pugh class B/C and MELD score >15 (p = 0.049 and p = 0.018, respectively). In male patients, a higher prevalence of sexual dysfunction was found among smokers patients (p = 0.045; OR = 0.18; 95% CI [0.03; 1.05]) and them who consumed alcohol (p = 0.042; OR = 0.19; 95% CI [0.04; 0.94]). In multivariate analysis, only alcohol consumption was independently associated with male sexual dysfunction (p = 0.041; OR = 9.187). MELD score >15

Conclusion

In conclusion, our study highlights the high frequency of sexual disorders in cirrhotic patients and identifies several associated factors, notably the severity of liver disease, socioeconomic
status, and certain comorbidities. For these reasons, screening and appropriate management of sexual dysfunction is essential in cirrhotic patients especialy with advanced disease or comorbidities.

Introduction

Chronic liver disease (CLD) is a major cause of morbidity and mortality. However, there are poorly established metrics to assess the quality of end-of-life (EOL) care in this context. Offering better care to who is dying is an important mission of health professionals, but EOL interventions can be futile, prolong suffering and consume resources better allocated to other needs.

Aims & Methods

Our goal was to characterize and compare the EOL of patients with CLD and compare them. We did a retrospective cohort study including all patients who died with CLD between 2012-2021 in charge of Gastroenterology, in a tertiary hospital.

Results

We included 72 patients, 89% male, with a mean age of 64±11 years. 68% of patients were Child-Pugh C and 50% had HCC. In the last 6 months of life, patients had a median of 2 (IQR 1-6) hospitalizations, and they were hospitalized a median of 21.5 (IQR 13.25-38.5) days, 15 (IQR 9.25-24.5) in the last month. Only 38% were referred to palliative care (PC), with a median of 5 (IQR 2-15) days between referral and death. 86% of patients had prescribed do-not-resuscitate order, with a median of 3 (IQR 1-9) days between this and death. In 42% of patients, endoscopic procedures were performed in the last hospitalization. In 58% and 17% of patients, it was documented in the clinical process discussion of the prognosis with the family and the patient, respectively. There was a significant difference between patients with and without HCC in their referral to PC (78% vs 47%, p=0.007) and sharing the prognosis with the patient (31% vs 19%, p=0.002).

Conclusion

In this cohort, there was a low and late referral to PC in general, being lower in the group of patients without HCC. It is imperative to select and apply quality of death metrics in patients with CLD, with and without HCC, aiming to improve care, manage expectations and resources.

Introduction

Hyponatremia is a frequent complication of cirrhosis and is a prognostic factor correlated with the severity of cirrhosis and influencing survival and the occurrence of complications, but this relationship is not yet well defined.

Aims & Methods

This was a single-centre retrospective descriptive and analytical study, including all cirrhotic patients admitted to our department in ascitic decompensation with hyponatremia between January 2019 and march 2025. The natremia threshold of 130 mmol/l was chosen because it is widely accepted to define hyponatraemia in cirrhotic patients. In our study, we compared 2 groups of patients: group A: fluid restriction + albumin infusion and group B: fluid restriction alone. Predictive factors of hyponatremia development and its impact on the outcome were evaluated. The aim of this study was to identify predictive factors of hyponatremia in cirrhotic patients with ascites, assess its prognostic impact on complications and survival, and compare the effectiveness of two treatment strategies—fluid restriction alone versus fluid restriction combined with albumin infusion—in correcting hyponatremia and improving clinical outcomes.

Results

Out of a total of 127 cirrhotic patients, forty patients with ascites and hyponatraemia (Na < 130 mmol/L) were included in the comparative analysis. These patients were divided into two groups: twenty patients received fluid restriction combined with albumin infusion (group A), and twenty patients received fluid restriction alone (group B). The mean age across both groups was 54.7 years, ranging from 19 to 80 years, with a sex ratio M/F of 0.7.
The causes of liver cirrhosis in our patients were: autoimmune (n=15), viral (n=11), undetermined (n=9), metabolic (n=2), genetic (n=2) and alcoholic (n=1).
Child-Pugh stage was B in 55% and C in 45%. The mean MELD score was 18 [7-48]. The prevalence of dilutional hyponatremia as defined by a serum sodium concentration ≤130 mmol/L or ≤135 mmol/L was 10.5% and 31.4% respectively.
The mean MELD score was 18, ranging from 7 to 48. The prevalence of dilutional hyponatremia, defined as serum sodium ≤130 mmol/L or ≤135 mmol/L, was 10.5% and 31.4%, respectively. A serum sodium level ≤130 mmol/L was significantly associated with more advanced liver disease, including Child-Pugh C (OR=7.84; p<0.001) and MELD >16 (OR=6.76; p=0.001).
Group A demonstrated a significantly greater improvement in natremia (mean increase of 4.5 mmol/L versus 1.2 mmol/L in group B; p=0.02), as well as a lower incidence of complications such as hepatic encephalopathy and hepatorenal syndrome. Although the difference in global survival at one year between the two groups (33.3% in group A vs. 12.5% in group B) The main precipitating factors of hyponatremia identified were excessive diuretic use (n=18), spontaneous bacterial peritonitis (n=12), gastrointestinal bleeding (n=6) and constipation (n=4). In several cases (n=8), multiple triggers were observed concurrently. The presence of hyponatremia was associated with a higher incidence of complications during hospitalization. Survival without complications was significantly reduced in patients with hyponatremia when a serum sodium concentration ≤135 mmol/L was used as the threshold (p=0.012). Moreover, survival free from hepatic encephalopathy and hepatorenal syndrome was significantly lower in hyponatremic patients (p<0.0001).
Analysis of prognostic factors revealed that serum sodium ≤130 mmol/L (HR=2.92; p=0.004), Child-Pugh C stage (HR=3.45; p=0.002), MELD score >18 (HR=2.67; p=0.007), and development of hepatic encephalopathy or hepatorenal syndrome during hospitalization (HR=4.21; p<0.001) were significantly associated with poor outcomes. Treatment of hepatic encephalopathy included systematic use of rifaximin and lactulose alongside management of the underlying precipitating factor. Overall survival at one year was significantly lower in patients with hyponatremia (22.5% vs. 68.7%), as was mean global survival (8.3 months vs. 32.8 months; p<0.0001).

Conclusion

Low serum sodium levels were significantly associated with more advanced liver disease and increased short-term morbidity and mortality in cirrhotic patients with ascites. Our findings suggest that albumin infusion, in addition to fluid restriction, is more effective in correcting hyponatremia and may help reduce the incidence of severe complications such as hepatic encephalopathy and hepatorenal syndrome. Therefore, serum sodium appears to be a valuable prognostic marker. The clinical benefit of correcting hyponatremia should be further confirmed in larger prospective studies.