Introduction
Sarcopenia defined as having low muscle mass, muscle strength and if combined with low performance indicate severe sarcopenia1. It is associated with adverse outcomes in cirrhosis, including hepatic encephalopathy, ascites, infection, and increased hospitalisation. Prevalence of sarcopenia has been reported between 40 to 70% and are more common with alcoholic liver disease2.
Aims & Methods
We aim to assess relationship between nutritional status/assessment, muscle quality and sarcopenia. Cirrhotic patients were recruited from a tertiary-hepatology-clinic for this prospective cross-sectional study. BIA was performed as the standard (SECA mBCA-525) for nutritional status and sarcopenia assessment. Appendicular skeletal muscle mass (ASM) calculated through sum of limb muscle masses in kg. sarcopenia was diagnosed with ASM/height2<7.0 kg/m2 and <5.5 kg/m2 for male and female respectively. Muscle quality was measured by mean handgrip strength in kg divided by ASM (HGS/ASM). Validated functional muscle metrics (handgrip and sit-to-stand), liver-frailty-index (LFI)3, Chronic Liver Disease Questionnaire (CLD-Q)4 and food-frequency-questionnaire (FFQ) were also analysed.
Results
49 patients, 57% (28) alcohol-liver-disease, 18% (9) non-alcoholic steatohepatitis, 5% (4) viral, 4% (3) autoimmune and 7% (5) mixed aetiologies, were included. 44 healthy controls (HC) were recruited as well. Most patients were male (n=28, 57%), with mean age 56yrs (SD=9), mean Child-Pugh score 6 (IQR= 5-7) and MELD 10 (IQR= 7-12). 35% (n=17) were actively drinking alcohol. 9 (18%) of patients were frail and 34 (69%) were pre-frail. 25 (89%) cirrhotic male and 14 (66%) cirrhotic female had sarcopenia diagnosed via BIA. 24/42 (57%) had lower total daily energy intake than is recommended by EASL guidelines5. Of those, 11 (44%) male and 6 (42%) had diagnosis of sarcopenia.
There was positive correlation between nutritional status measured with BIA as Phase angle analysis (PhA) with total skeletal muscle mass adjusted for height, SMM/H2, (r=0.51, p<0.0001) and ASM/H2 (r=0.04,p=0.7). There was strong correlation between PhA and HGS (r=0.71, p=<0.001). Higher PhA score predicts lower MELD score therefore longer survivals (β = -0.092, p=0.004).
Healthy control has significantly better muscle quality (HGS/ASM) compared to cirrhotic patient (mean 2.52 vs 1.85 kg, SD 0.6 and 0.4 respectively, p<0.001).
Using functional testing, sit-to-stand time was lower in HCs (13.35 vs 8.94 secs, p=0.0001) and hand-grip strength higher in HC (p< 0.001). QoL was negatively correlate with sarcopenia (r=-0.06,p=0.6), LFI (r=-0.2,p=0.1), MELD (r=-0.15,p=0.3) and Child-Pugh score (r= -0.08, p=0.6) although they were not statically significant.
Conclusion
Cirrhotic patients had lower muscle quality and functional status compared to HC. FFQ and PhA are good assessment tool to establish nutritional status. PhA correlated much better with SMM/H2 than ASM/H2 and is a good predictor for disease severity. QoL is multifactorial and couldn’t be explained with frailty scores or clinical severity scores.
References
1. Alfonso J Cruz-Jentoft et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019 Jan 1;48(1):16-31
2. Xinxing Tantai et al. Effect of sarcopenia on survival in patients with cirrhosis: A meta-analysis Journal of Hepatology 2022 vol. 76 j 588–599
3. Jennifer C Lai et al. Development of a novel frailty index to predict mortality in patients with end-stage liver disease. Hepatology 2017 Aug;66(2):564-574
4. Z M Younossi et al. Development of a disease specific questionnaire to measure health related quality of life in patients with chronic liver disease. Gut 1999;45:295–300
5. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol. 2019 Jan;70(1):172-193.