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1
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Iannelli A, Carandina S. Comment on: Bariatric surgery prior to pancreas transplantation: a retrospective matched case-control study. Surg Obes Relat Dis 2025; 21:e17-e18. [PMID: 40064581 DOI: 10.1016/j.soard.2025.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2024] [Accepted: 01/26/2025] [Indexed: 05/12/2025]
Affiliation(s)
- Antonio Iannelli
- University of Nice Côte d'Azur, Nice, France; ELSAN, Clinique Saint Michel, Centre de Chirurgie de l'Obésité (CCO), Toulon, France; Adipocible Research Study Group, Université Nice Côte d'Azur and Initiative d'Excellence - Idex, Nice, France
| | - Sergio Carandina
- ELSAN, Clinique Saint Michel, Centre de Chirurgie de l'Obésité (CCO), Toulon, France
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2
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Utakata Y, Miwa T, Hanai T, Aiba M, Unome S, Imai K, Shirakami Y, Takai K, Shimizu M. Usefulness of Retinol-Binding Protein in Predicting Mortality in Patients With Chronic Liver Disease. JGH Open 2025; 9:e70087. [PMID: 39927287 PMCID: PMC11806657 DOI: 10.1002/jgh3.70087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Revised: 12/11/2024] [Accepted: 12/16/2024] [Indexed: 02/11/2025]
Abstract
Background and Aim Rapid turnover proteins (RTPs), including retinol-binding protein (RBP), prealbumin, and transferrin, are useful in evaluating dynamic nutritional status. This study aimed to investigate the relationship between serum RTP levels and mortality in patients with chronic liver disease (CLD). Methods We evaluated 341 patients with CLD admitted between October 2011 and December 2021. Those with RBP levels below 2.7 mg/dL for males and 1.9 mg/dL for females were included in the low RBP group. Factors associated with mortality and low RBP were evaluated using the Cox proportional hazard regression and logistic regression models. Results The median age of the included patients was 67 years, and 48% were male. The median model for end-stage liver disease (MELD) score was 8 points, and the median RBP, prealbumin, and transferrin levels were 1.5 mg/dL, 11 mg/dL, and 227 mg/dL, respectively. During a median observational period, 23% of the patients died. Multivariate analysis showed that the RBP level (hazard ratio, 0.62; 95% confidence interval [CI], 0.46-0.81) was independently associated with mortality, while prealbumin and transferrin were not. Additional analysis revealed that male sex (odds ratio, 8.62; 95% CI, 2.56-29.00) and albumin level (odds ratio, 0.10; 95% CI, 0.04-0.26) were significantly associated with the low RBP levels in patients with CLD. Conclusions The serum RBP level is a dynamic biomarker associated with mortality in patients with CLD, independent of liver functional reserve, and it may be a useful indicator for nutritional intervention in these patients.
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Affiliation(s)
- Yuki Utakata
- Department of Gastroenterology/Internal MedicineGifu University HospitalGifuJapan
- Department of GastroenterologyChuno Kosei HospitalSekiJapan
| | - Takao Miwa
- Department of Gastroenterology/Internal MedicineGifu University HospitalGifuJapan
| | - Tatsunori Hanai
- Department of Gastroenterology/Internal MedicineGifu University HospitalGifuJapan
- Center for Nutrition Support and Infection ControlGifu University HospitalGifuJapan
| | - Masashi Aiba
- Department of Gastroenterology/Internal MedicineGifu University HospitalGifuJapan
| | - Shinji Unome
- Department of Gastroenterology/Internal MedicineGifu University HospitalGifuJapan
| | - Kenji Imai
- Department of Gastroenterology/Internal MedicineGifu University HospitalGifuJapan
| | - Yohei Shirakami
- Department of Gastroenterology/Internal MedicineGifu University HospitalGifuJapan
| | - Koji Takai
- Department of Gastroenterology/Internal MedicineGifu University HospitalGifuJapan
- Division for Regional Cancer ControlGraduate School of Medicine, Gifu UniversityGifuJapan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal MedicineGifu University HospitalGifuJapan
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Elsabaawy M. Liver at crossroads: unraveling the links between obesity, chronic liver diseases, and the mysterious obesity paradox. Clin Exp Med 2024; 24:240. [PMID: 39402270 PMCID: PMC11473604 DOI: 10.1007/s10238-024-01493-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Accepted: 09/20/2024] [Indexed: 10/19/2024]
Abstract
Obesity is a global health issue that is intricately linked to the development and progression of chronic liver disease (CLD). This bidirectional connection, coupled with the obesity paradox (OP), presents a management dilemma. The established influence of obesity on the development and progression of chronic liver disease (CLD) is surpassed by the liver's impact on the onset and advancement of obesity. Patients with CLD always experience increased energy expenditure, reduced appetite, and low protein synthesis, all of which might lead to weight loss. However, metabolic disturbances, hormonal imbalances, inflammatory signaling, immobility, drugs, and alterations in nutrient metabolism can contribute to the development and exacerbation of obesity. Despite the propagation of the OP concept, none of the guidelines has changed, recommending being overweight. Research bias and confounders might be the lifebuoy explanation. Additionally, overlooking the lethal morbidities of obesity for survival benefits full of suffering seems to be an illogical idea. Therefore, rather than endorsing an overweight status, emphasis should be placed on improving cardiorespiratory fitness and preventing sarcopenia to achieve better outcomes in patients with CLD. Accordingly, the complex interplay between obesity, CLD, and the concept of OP requires a sophisticated individualized management approach. Maximizing cardiorespiratory fitness and mitigating sarcopenia should be considered essential strategies for attaining the most favourable outcomes in patients with chronic liver disease (CLD).
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Affiliation(s)
- Maha Elsabaawy
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt.
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Endo K, Kakisaka K, Abe T, Yusa K, Nakaya I, Watanabe T, Suzuki A, Yoshida Y, Oikawa T, Miyasaka A, Kuroda H, Matsumoto T. Positive impact of obesity on the prognosis of liver cirrhosis. J Gastroenterol Hepatol 2024; 39:1663-1672. [PMID: 38700075 DOI: 10.1111/jgh.16590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/04/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND AND AIM The study aims to determine the prognostic impact of obesity, sarcopenic obesity, and dynapenic obesity in patients with chronic liver disease. METHODS This retrospective observational study enrolled patients with chronic hepatitis (n = 746) and liver cirrhosis (n = 434) without hepatocellular carcinoma at entry. The patients were evaluated for sarcopenia and obesity between April 2016 and April 2022. Obesity was defined as a body mass index of ≥ 25 kg/m2. Sarcopenic obesity was defined as low skeletal muscle mass (pre-sarcopenia) with obesity and dynapenic obesity was defined as low muscle strength (dynapenia) with obesity. The effects of obesity on survival were evaluated retrospectively. RESULTS The mean observation period was 2.5 years. Obesity, sarcopenic obesity, and dynapenic obesity were found in 271 (45.5%), 17 (2.9%), and 21 (3.5%) men, and 261 (44.7%), 59 (10.1%), and 53 (9.1%) women, respectively. A multivariate Cox proportional hazards model revealed that Child-Pugh class, dynapenia (hazard ratio [HR] 3.89), elderly (≥ 65 years old) (HR 2.11), and obesity (HR 0.58) were independently associated with overall survival (OS). However, neither sarcopenic nor dynapenic obesity were associated with OS. In patients with cirrhosis, the OS of the obese group was significantly higher than that of the non-obese group. The effect of obesity on OS was significant in elderly patients, but not in younger patients. CONCLUSIONS Sarcopenic and dynapenic obesity seem unrelated to the prognosis of patients with chronic liver disease. Obesity has a positive effect on the prognosis of elderly patients with cirrhosis.
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Affiliation(s)
- Kei Endo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Keisuke Kakisaka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Tamami Abe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Kenji Yusa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Ippeki Nakaya
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Takuya Watanabe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Akiko Suzuki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Yuichi Yoshida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Takayoshi Oikawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Akio Miyasaka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Hidekatsu Kuroda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
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Behari J, Wang R, Luu HN, McKenzie D, Molinari M, Yuan JM. Severe obesity is associated with worse outcomes than lean metabolic dysfunction-associated steatotic liver disease. Hepatol Commun 2024; 8:e0471. [PMID: 38934706 PMCID: PMC11213590 DOI: 10.1097/hc9.0000000000000471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/25/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Metabolic dysfunction-associated steatotic liver disease (MASLD) is highly prevalent in people with obesity. We aimed to study the association of body mass index (BMI) with clinical outcomes in patients with MASLD. METHODS A retrospective cohort of 32,900 patients with MASLD, identified through the International Classification of Diseases-9 and 10 codes within the electronic health records of a large US-based health system, with a mean follow-up of 5.5 years (range: 1-15 y), was stratified into 6 BMI categories, <25, 25-<30, 30-<40, 40-<50, and ≥50 kg/m2. RESULTS The risk of liver decompensation and extrahepatic obesity-associated cancers had a J-shaped profile (both ps for linear and quadratic terms <0.05). Compared to patients with BMI 25-<30 kg/m2, the adjusted HRs (95% CIs) for liver decompensation of patients with BMI <25 and BMI ≥50 kg/m2 were 1.44 (1.17-1.77) and 2.27 (1.66-3.00), respectively. The corresponding figures for obesity-associated extrahepatic cancer were 1.15 (0.97-1.36) and 1.29 (1.00-1.76). There was an inverse association for BMI with liver transplantation and non-obesity-associated cancer (both ps for linear terms <0.05), but no association with HCC or all types of cancers combined. A similar J-shaped association between BMI and all-cause mortality was observed; adjusted HRs (95% CIs) for BMI <25 and ≥50 kg/m2 were 1.51 (1.32-1.72) and 3.24 (2.67-3.83), respectively, compared with BMI 25-<30 kg/m2 (both ps for linear and quadratic terms <0.001). CONCLUSIONS Patients with MASLD and very severe obesity (BMI ≥50 kg/m2) had the highest risk, exceeding that of patients with lean MASLD, for developing liver decompensation, obesity-associated extrahepatic cancers, or dying from any cause.
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Affiliation(s)
- Jaideep Behari
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Cancer Epidemiology and Prevention Program, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Renwei Wang
- Cancer Epidemiology and Prevention Program, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Hung N. Luu
- Cancer Epidemiology and Prevention Program, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - David McKenzie
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michele Molinari
- Department of Surgery, Division of Transplant Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jian-Min Yuan
- Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Cancer Epidemiology and Prevention Program, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
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Wakabayashi SI, Tamaki N, Kimura T, Umemura T, Kurosaki M, Izumi N. Natural history of lean and non-lean metabolic dysfunction-associated steatotic liver disease. J Gastroenterol 2024; 59:494-503. [PMID: 38570344 DOI: 10.1007/s00535-024-02093-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/29/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Conflicting evidence regarding the prognosis of lean metabolic dysfunction-associated steatotic liver disease (MASLD) has raised substantial questions. AIM This study aimed to elucidate the prognosis of lean MASLD by conducting a comprehensive analysis of a vast Asian cohort. METHODS This study used a nationwide, population-based database and analyzed 2.9 million patients. The primary endpoints were liver-related events (LREs) and cardiovascular events (CVEs) in patients with lean MASLD, non-lean MASLD, and normal liver control groups. RESULTS The median observation period was 4.2 years. The 5-year incidence values of LREs in the lean MASLD, non-lean MASLD, and normal liver control groups were 0.065%, 0.039%, and 0.006%, respectively. The LRE risk of lean MASLD was significantly higher than that of normal liver control (adjusted hazard ratio [aHR]: 5.94, 95% confidence interval [CI]: 3.95-8.92) but comparable to that of non-lean MASLD (aHR: 1.35, 95% CI: 0.87-2.08). By contrast, for CVEs, the non-lean MASLD group exhibited a higher 5-year cumulative incidence rate (0.779%) than the lean MASLD (0.600%) and normal liver control (0.254%) groups. The lean MASLD group had a reduced risk of CVEs compared with the non-lean MASLD group (aHR, 0.73; 95% CI: 0.64-0.84), and comparable risk of CVEs to the normal liver control group (aHR, 0.99; 95% CI: 0.88-1.12). CONCLUSION Lean MASLD exhibits a similar LRE risk and a lower CVE risk to non-lean MASLD. Therefore, follow-up and treatment strategies should be tailored to the specific MASLD condition.
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Affiliation(s)
- Shun-Ichi Wakabayashi
- Division of Gastroenterology, Department of Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Nobuharu Tamaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, 1-26-1 Kyonan-Cho, Musashino-Shi, Tokyo, 180-8610, Japan
| | - Takefumi Kimura
- Division of Gastroenterology, Department of Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Takeji Umemura
- Division of Gastroenterology, Department of Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Masayuki Kurosaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, 1-26-1 Kyonan-Cho, Musashino-Shi, Tokyo, 180-8610, Japan.
| | - Namiki Izumi
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, 1-26-1 Kyonan-Cho, Musashino-Shi, Tokyo, 180-8610, Japan
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7
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Keshoofi P, Schindler P, Rennebaum F, Cordes F, Morgul H, Wildgruber M, Heinzow HS, Pascher A, Schmidt HH, Hüsing-Kabar A, Praktiknjo M, Trebicka J, Seifert LL. Imaging-based diagnosis of sarcopenia for transplant-free survival in primary sclerosing cholangitis. BMC Gastroenterol 2024; 24:145. [PMID: 38664624 PMCID: PMC11044284 DOI: 10.1186/s12876-024-03232-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 04/16/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Imaging-based assessment of sarcopenia is a well-validated prognostic tool for patients with chronic liver disease. However, little is known about its value in patients with primary sclerosing cholangitis (PSC). This cross-sectional study aimed to investigate the predictive value of the cross-sectional imaging-based skeletal muscle index (SMI) for transplant-free survival (TFS) in patients with PSC. METHODS A total of 95 patients with PSC who underwent abdominal cross-sectional imaging between 2008 and 2022 were included in this retrospective study. SMI was measured at the third lumbar vertebra level (L3-SMI). The cut-off values to define sarcopenia were < 50 cm²/m² in male patients and < 39 cm²/m² in female patients. The primary outcome of this study was TFS, which was defined as survival without liver transplantation or death from any cause. RESULTS Our study indicates that L3-SMI sarcopenia impairs TFS in patients with PSC (5-year TFS: 33.9% vs. 83.3%, p = 0.001, log-rank test). L3-SMI sarcopenia was independently associated with reduced TFS via multivariate Cox regression analysis (HR = 2.749; p = 0.028). Body mass index reduction > 10% at 12 months, which is used as MELD standard exception (SE) criterion in Eurotransplant (in Germany only until September 2023), was not significantly associated with TFS in the multivariate Cox regression analysis (HR = 1.417; p = 0.330). Substitution of BMI reduction with L3-SMI in the German SE criteria improved the predictive accuracy of TFS compared to the established SE criteria (multivariable Cox regression analysis: HR = 4.007, p < 0.001 vs. HR = 1.691, p = 0.141). CONCLUSION Imaging-based diagnosis of sarcopenia via L3-SMI is associated with a low TFS in patients with PSC and may provide additional benefits as a prognostic factor in patient selection for liver transplantation.
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Affiliation(s)
- Pedram Keshoofi
- Medical Clinic B, Department of Gastroenterology, Hepatology, Endocrinology, Infectiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Bldg. A14, 48149, Muenster, Germany.
| | - Philipp Schindler
- Clinic for Radiology, University Hospital Muenster, 48149, Muenster, Germany
| | - Florian Rennebaum
- Medical Clinic B, Department of Gastroenterology, Hepatology, Endocrinology, Infectiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Bldg. A14, 48149, Muenster, Germany
| | - Friederike Cordes
- Medical Clinic II, Euregio Hospital Nordhorn, 48529, Nordhorn, Germany
| | - Haluk Morgul
- Department for General, Visceral and Transplant Surgery, University Hospital Muenster, 48149, Muenster, Germany
| | - Moritz Wildgruber
- Department of Radiology, University Hospital LMU Munich, 81377, Munich, Germany
| | - Hauke S Heinzow
- Department of Internal Medicine I, Krankenhaus der Barmherzigen Brüder, 54292, Trier, Germany
| | - Andreas Pascher
- Department for General, Visceral and Transplant Surgery, University Hospital Muenster, 48149, Muenster, Germany
| | - Hartmut H Schmidt
- Department of Gastroenterology, Hepatology and Transplantation Medicine, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Anna Hüsing-Kabar
- Medical Clinic B, Department of Gastroenterology, Hepatology, Endocrinology, Infectiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Bldg. A14, 48149, Muenster, Germany
| | - Michael Praktiknjo
- Medical Clinic B, Department of Gastroenterology, Hepatology, Endocrinology, Infectiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Bldg. A14, 48149, Muenster, Germany
| | - Jonel Trebicka
- Medical Clinic B, Department of Gastroenterology, Hepatology, Endocrinology, Infectiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Bldg. A14, 48149, Muenster, Germany
| | - Leon Louis Seifert
- Medical Clinic B, Department of Gastroenterology, Hepatology, Endocrinology, Infectiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Bldg. A14, 48149, Muenster, Germany.
- The Rockefeller University Center for Clinical and Translational Science, 10065, New York, NY, United States of America.
- Laboratory of Virology and Infectious Disease, The Rockefeller University, 10065, New York, NY, United States of America.
- The Rockefeller University Hospital, 1230 York Avenue, 10065, New York, NY, USA.
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Cruz C, Prado CM, Gillis C, Martindale R, Bémeur C, Lai JC, Tandon P. Nutritional aspects of prehabilitation in adults with cirrhosis awaiting liver transplant. Hepatology 2024:01515467-990000000-00825. [PMID: 38546288 PMCID: PMC11828479 DOI: 10.1097/hep.0000000000000818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/20/2024] [Indexed: 04/21/2024]
Abstract
Malnutrition, sarcopenia (low muscle mass), and physical frailty have gained increasing recognition in candidates for liver transplant (LT) as these conditions can impact postoperative functional capacity. Multidimensional prehabilitation programs have been proposed as a safe intervention in adults awaiting LT but the nutritional pillar of prehabilitation has been understudied. This review summarizes the nutritional recommendations for prehabilitation for individuals with cirrhosis awaiting LT. Three major aspects of nutritional prehabilitation are discussed: (1) Assess: Evaluate nutritional status and assess for malnutrition, sarcopenia, and frailty to guide the nutritional prehabilitation intervention intensity, increasing across universal, targeted, and specialist levels; (2) Intervene: Prescribe a nutritional prehabilitation intervention to meet established nutrition guidelines in cirrhosis with a targeted focus on improving nutritional status and muscle health; (3) Reassess: Follow-up based on the required intensity of nutritional care with as needed intervention adjustment. Topics covered in the review include nutritional care levels for prehabilitation, energy prescriptions across body mass index strata, detailed considerations around protein intake (amount, distribution, and quality), carbohydrate and fat intake, other nutritional considerations, and the potential role of dietary supplements and nutraceuticals. Future research is warranted to more accurately evaluate energy needs, evaluate emerging dietary supplementation strategies, and establish the role of nutraceuticals alongside food-based interventions. While the general principles of nutritional prehabilitation are ready for immediate application, future large-scale randomized controlled trials in this space will help to quantify the benefit that can be gained by transitioning the LT approach from passive "transplant waitlist time" to active "transplant preparation time."
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Affiliation(s)
- Christofer Cruz
- Department of Medicine, Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Carla M. Prado
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Chelsia Gillis
- School of Human Nutrition, McGill University, Montreal, Quebec, Canada
- Departments of Anesthesia & Surgery, McGill University, Montreal, Quebec, Canada
| | - Robert Martindale
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California, USA
| | - Chantal Bémeur
- Department of Nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Jennifer C. Lai
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Puneeta Tandon
- Department of Medicine, Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
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9
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deLemos AS, Zhao J, Patel M, Kooken B, Mathur K, Nguyen HM, Mazhar A, McCarter M, Burney H, Kettler C, Chalasani N, Gawrieh S. Lean body mass index is a marker of advanced tumor features in patients with hepatocellular carcinoma. World J Hepatol 2024; 16:393-404. [PMID: 38577534 PMCID: PMC10989303 DOI: 10.4254/wjh.v16.i3.393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/31/2023] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Obesity is an independent risk factor for the development of hepatocellular carcinoma (HCC) and may influence its outcomes. However, after diagnosis of HCC, like other malignancies, the obesity paradox may exist where higher body mass index (BMI) may in fact confer a survival benefit. This is frequently observed in patients with advanced HCC and cirrhosis, who often present late with advanced tumor features and cancer related weight loss. AIM To explore the relationship between BMI and survival in patients with cirrhosis and HCC. METHODS This is a retrospective cohort study of over 2500 patients diagnosed with HCC between 2009-2019 at two United States academic medical centers. Patient and tumor characteristics were extracted manually from medical records of each institutions' cancer registries. Patients were stratified according to BMI classes: < 25 kg/m2 (lean), 25-29.9 kg/m2 (overweight), and > 30 kg/m2 (obese). Patient and tumor characteristics were compared according to BMI classification. We performed an overall survival analysis using Kaplan Meier by the three BMI classes and after adjusting for Milan criteria. A multivariable Cox regression model was then used to assess known risk factors for survival in patients with cirrhosis and HCC. RESULTS A total of 2548 patients with HCC were included in the analysis of which 11.2% (n = 286) were classified as non-cirrhotic. The three main BMI categories: Lean (n = 754), overweight (n = 861), and obese (n = 933) represented 29.6%, 33.8%, and 36.6% of the total population overall. Within each BMI class, the non-cirrhotic patients accounted for 15% (n = 100), 12% (n = 94), and 11% (n = 92), respectively. Underweight patients with a BMI < 18.5 kg/m2 (n = 52) were included in the lean cohort. Of the obese cohort, 42% (n = 396) had a BMI ≥ 35 kg/m2. Out of 2262 patients with cirrhosis and HCC, 654 (29%) were lean, 767 (34%) were overweight, and 841 (37%) were obese. The three BMI classes did not differ by age, MELD, or Child-Pugh class. Chronic hepatitis C was the dominant etiology in lean compared to the overweight and obese patients (71%, 62%, 49%, P < 0.001). Lean patients had significantly larger tumors compared to the other two BMI classes (5.1 vs 4.2 vs 4.2 cm, P < 0.001), were more likely outside Milan (56% vs 48% vs 47%, P < 0.001), and less likely to undergo transplantation (9% vs 18% vs 18%, P < 0.001). While both tumor size (P < 0.0001) and elevated alpha fetoprotein (P < 0.0001) were associated with worse survival by regression analysis, lean BMI was not (P = 0.36). CONCLUSION Lean patients with cirrhosis and HCC present with larger tumors and are more often outside Milan criteria, reflecting cancer related cachexia from delayed diagnosis. Access to care for hepatitis C virus therapy and liver transplantation confer a survival benefit, but not overweight or obese BMI classifications.
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Affiliation(s)
| | - Jing Zhao
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC 28204, United States
| | - Milin Patel
- Department of Medicine, Atrium Health, Charlotte, NC 28204, United States
| | - Banks Kooken
- Department of Medicine, Atrium Health, Charlotte, NC 28204, United States
| | - Karan Mathur
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States
| | - Hieu Minh Nguyen
- Center for Health System Sciences (CHASSIS), Atrium Health, Charlotte, NC 28204, United States
| | - Areej Mazhar
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States
| | - Maggie McCarter
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC 28204, United States
| | - Heather Burney
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN 46202, United States
| | - Carla Kettler
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN 46202, United States
| | - Naga Chalasani
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN 46202, United States
| | - Samer Gawrieh
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN 46202, United States
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10
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Lee DU, Bahadur A, Ponder R, Lee KJ, Fan GH, Chou H, Lominadze Z. The causes of death in patients with nonalcoholic steatohepatitis following liver transplantation stratified using pre-liver transplant BMI. Hepatol Int 2023; 17:1393-1415. [PMID: 37160862 PMCID: PMC10767727 DOI: 10.1007/s12072-023-10529-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/18/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND & AIMS Determining the effects of pre-liver transplant (LT) BMI independent of underlying ascites on the post-LT outcomes of patients with nonalcoholic steatohepatitis (NASH) is needed to clarify the paradoxical and protective effects of obesity on post-LT endpoints. In order to accomplish this, we used graded severities of ascites to stratify the NASH-LT population and to perform an ascites-specific strata analysis with differing pre-LT BMI levels. METHODS 2005-2019 United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research (STAR) database was queried to select patients with NASH, who were categorized into specific sets of ascites severity: no ascites (n = 1188), mild ascites (n = 4463), and moderate ascites (n = 3525). Then, BMI classification (underweight: < 18.5, normal: 18.5-25, overweight: 25-30, obese: ≥ 30 kg/m2) was used to stratify each ascites-specific group and to compare to the post-LT mortality endpoints. Those under 18 years old and those who received living/multi-organ transplants were excluded. RESULTS Among each ascites category, there were the following numbers of normal, underweight, overweight, and obese BMI patients respectively; no ascites: 161, 4, 359, 664; mild ascites: 643, 28, 1311, 2481; and moderate ascites: 529, 25, 1030, 1941. The obese BMI cohort was at a lower risk of all-cause mortality compared to recipients with normal BMI with mild ascites (aHR: 0.79, 95% Confidence Interval (CI) 0.65-0.94, p-value = 0.010; case-incidence 47.10 vs 56.81 deaths per 1000 person-years) and moderate ascites (aHR: 0.77, 95% CI 0.63-0.94, p-value = 0.009; case-incidence 53.71 vs 66.17 deaths per 1000 person-years). In addition, the overweight BMI cohort with mild ascites demonstrated a lower hazard of all-cause mortality (aHR: 0.80, 95% CI 0.66-0.97, p-value = 0.03; case-incidence 49.09 vs 56.81 deaths per 1000 person-years). There was no difference in graft failure for the three BMI groups (underweight, overweight, and obese) in comparison to normal BMI. Furthermore, the overweight BMI group with mild ascites cohort demonstrated a lower hazard of death due to general infectious causes (aHR: 0.51, 95% CI 0.32-0.83, p = 0.006; case-incidence 6.12 vs 11.91 deaths per 1000 person-years) and sepsis (aHR: 0.49, 95% CI 0.27-0.86, p = 0.01; case-incidence 4.31 vs 8.50 deaths per 1000 person-years). CONCLUSION The paradoxical effects of obesity in reducing the risks of all-cause death appears to be in part modulated by ascites. The current study emphasizes the need to evaluate BMI with concomitant ascites severity pre-LT to accurately prognosticate post-LT outcomes when evaluating NASH patients with advanced liver disease.
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Affiliation(s)
- David Uihwan Lee
- Division of Gastroenterology and Hepatology, University of Maryland, 620 W Lexington St, Baltimore, MD, 21201, USA.
- Liver Center, Division of Gastroenterology and Hepatology, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD, 21201, USA.
| | - Aneesh Bahadur
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA, 02111, USA
| | - Reid Ponder
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA, 02111, USA
| | - Ki Jung Lee
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA, 02111, USA
| | - Gregory Hongyuan Fan
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA, 02111, USA
| | - Harrison Chou
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA, 02111, USA
| | - Zurabi Lominadze
- Division of Gastroenterology and Hepatology, University of Maryland, 620 W Lexington St, Baltimore, MD, 21201, USA
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11
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Ha J, Yim SY, Karagozian R. Mortality and Liver-Related Events in Lean Versus Non-Lean Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2023; 21:2496-2507.e5. [PMID: 36442727 DOI: 10.1016/j.cgh.2022.11.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/09/2022] [Accepted: 11/11/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND & AIMS Although approximately 40% of patients with nonalcoholic fatty liver disease (NAFLD) are nonobese or lean, little is known about the long-term clinical outcomes of lean NAFLD. We aimed to estimate the risk of mortality and adverse liver-related events in patients with lean NAFLD compared with those with non-lean NAFLD. METHODS We searched the PubMed, Embase, and Cochrane Library databases through May 2022 for articles reporting mortality and/or development of cirrhosis among lean and non-lean NAFLD patients. The relative risks (RRs) of all-cause mortality, cardiovascular mortality, liver-related mortality, and occurrence of decompensated cirrhosis or hepatocellular carcinoma were pooled using the random-effects model. We also performed subgroup analysis according to characteristics of the study population, methods of NAFLD diagnosis, study design, study region, and length of follow-up. RESULTS We analyzed 10 cohort studies involving 109,151 NAFLD patients. Patients with lean NAFLD had comparable risks for all-cause mortality (RR, 1.09; 95% confidence interval [CI], 0.66-1.90), cardiovascular mortality (RR, 1.12; 95% CI, 0.66-1.90), and adverse liver events including decompensated cirrhosis and hepatocellular carcinoma (RR, 0.81; 95% CI, 0.50-1.30). However, the risk of liver-related mortality was higher in patients with lean than non-lean NAFLD (RR, 1.88; 95% CI, 1.02-3.45). CONCLUSIONS This study highlights a higher risk of liver-related mortality in patients with lean NAFLD than those with non-lean NAFLD. This finding indicates that further understanding of the pathophysiology, risk factors of adverse outcomes, and genetic and ethnic variabilities of lean NAFLD phenotype is warranted for individualized treatment strategies in lean NAFLD patients.
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Affiliation(s)
- Jane Ha
- Clinical and Translational Epidemiology Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sun Young Yim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Raffi Karagozian
- Department of Gastroenterology and Hepatology, Tufts Medical Center, Boston, Massachusetts.
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12
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Cimsit C, Kursun M, Demircioglu O, Dilber F, Demirtas CO, Ergenc I. Radiological Quantification of Sarcopenic Obesity and its Role in Chronic Liver Disease Severity. Acad Radiol 2023; 30 Suppl 1:S124-S131. [PMID: 37012127 DOI: 10.1016/j.acra.2023.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/26/2023] [Accepted: 03/01/2023] [Indexed: 04/04/2023]
Abstract
RATIONALE AND OBJECTIVES To define sarcopenic obesity (SaO) among chronic liver disease (CLD) patients via CT and MRI, and assess its impact on liver disease severity. MATERIALS AND METHODS CLD patients referred from the Gastroenterology and Hepatology Department diagnosed as chronic hepatitis B (N:101), cirrhosis (N:110), and hepatocellular carcinoma (N:169) with available information on body height, weight, Child-Pugh and MELD scores within 2 weeks of CT or MRI scanning were included in the study. Cross-sectional examinations were retrospectively evaluated for skeletal muscle index (SMI) and visceral adipose tissue area (VATA). The disease severity was assessed by Child-Pugh and MELD scoring. RESULTS The rate of sarcopenia and SaO in the cirrhotic patients was higher than that in the chronic hepatitis B patients (p <0.033 and p < 0.004, respectively). The rate of sarcopenia and SaO in HCC patients was higher than that in the chronic hepatitis B patients (p <0.001 and p <0.001, respectively). Sarcopenic patients in Chronic hepatitis B, cirrhotic, and HCC groups had higher MELD scores than nonsarcopenic patients (p <0.035, p <0.023, and p <0.024, respectively). Despite finding a similar increase in Child-Pugh scores in cirrhotic and HCC sarcopenic patients, results were statistically insignificant (p <0.597 and p <0.688). HCC patients with SaO had higher MELD scores than patients with other body composition catagories (p <0.006). Cirrhotic patients with SaO had higher MELD scores than nonsarcopenic obese patients (p <0.049). Chronic hepatitis B patients with obesity had low MELD scores (p <0.035). Cirrhotic and HCC patients with obesity had higher MELD scores (p <0.01 and p <0.024, respectively). Cirrhotic and HCC patients with obesity had higher Child-Pugh scores than nonobese patients but only HCC patients showed statistically significance (p <0.480 and p <0.001). CONCLUSION Radiologic evaluation of SaO and harmonizing body composition with MELD scoring is critical in CLD management.
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Affiliation(s)
- Canan Cimsit
- Department of Radiology, Marmara University Faculty of Medicine, Marmara University Pendik Training and Research Hospital, Mimar Sinan Cad. No:41, Üst Kaynarca, 34899, Pendik, Istanbul, Turkey.
| | - Meltem Kursun
- Department of Radiology, Marmara University Faculty of Medicine, Marmara University Pendik Training and Research Hospital, Mimar Sinan Cad. No:41, Üst Kaynarca, 34899, Pendik, Istanbul, Turkey
| | - Ozlem Demircioglu
- Department of Radiology, Marmara University Faculty of Medicine, Marmara University Pendik Training and Research Hospital, Mimar Sinan Cad. No:41, Üst Kaynarca, 34899, Pendik, Istanbul, Turkey
| | - Feyza Dilber
- Department of Gastroenterology and Hepatology, Marmara University Faculty of Medicine, Marmara University Pendik Training and Research Hospital, Pendik, Istanbul, Turkey
| | - Coskun Ozer Demirtas
- Department of Gastroenterology and Hepatology, Marmara University Faculty of Medicine, Marmara University Pendik Training and Research Hospital, Pendik, Istanbul, Turkey
| | - Ilkay Ergenc
- Department of Gastroenterology and Hepatology, Marmara University Faculty of Medicine, Marmara University Pendik Training and Research Hospital, Pendik, Istanbul, Turkey
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13
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Czapla M, Kwaśny A, Słoma-Krześlak M, Juárez-Vela R, Karniej P, Janczak S, Mickiewicz A, Uchmanowicz B, Zieliński S, Zielińska M. The Impact of Body Mass Index on In-Hospital Mortality in Post-Cardiac-Arrest Patients-Does Sex Matter? Nutrients 2023; 15:3462. [PMID: 37571399 PMCID: PMC10420814 DOI: 10.3390/nu15153462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 07/28/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND A number of factors influence mortality in post-cardiac-arrest (CA) patients, nutritional status being one of them. The aim of this study was to assess whether there are sex differences in the prognostic impact of BMI, as calculated on admission to an intensive care unit, on in-hospital mortality in sudden cardiac arrest (SCA) survivors. METHODS We carried out a retrospective analysis of data of 129 post-cardiac-arrest patients with return of spontaneous circulation (ROSC) admitted to the Intensive Care Unit (ICU) of the University Teaching Hospital in Wrocław between 2017 and 2022. RESULTS Female patients were significantly older than male patients (68.62 ± 14.77 vs. 62.7 ± 13.95). The results of univariable logistic regression analysis showed that BMI was not associated with the odds of in-hospital death in either male or female patients. In an age-adjusted model, age was an independent predictor of the odds of in-hospital death only in male patients (OR = 1.034). In our final multiple logistic regression model, adjusted for the remaining variables, none of the traits analysed were a significant independent predictor of the odds of in-hospital death in female patients, whereas an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) was an independent predictor of the odds of in-hospital death in male patients (OR = 0.247). CONCLUSIONS BMI on admission to ICU is not a predictor of the odds of in-hospital death in either male or female SCA survivors.
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Affiliation(s)
- Michał Czapla
- Department of Emergency Medical Service, Wrocław Medical University, 51-616 Wrocław, Poland; (M.C.); (A.M.)
- Group of Research in Care (GRUPAC), Faculty of Health Sciences, University of La Rioja, 26006 Logroño, Spain; (R.J.-V.); (P.K.)
| | - Adrian Kwaśny
- Institute of Dietetics, Academy of Business and Health Science, 90-361 Łódź, Poland;
| | - Małgorzata Słoma-Krześlak
- Department of Human Nutrition, Department of Dietetics, Faculty of Health Sciences in Bytom, Medical University of Silesia in Katowice, 40-055 Katowice, Poland;
| | - Raúl Juárez-Vela
- Group of Research in Care (GRUPAC), Faculty of Health Sciences, University of La Rioja, 26006 Logroño, Spain; (R.J.-V.); (P.K.)
| | - Piotr Karniej
- Group of Research in Care (GRUPAC), Faculty of Health Sciences, University of La Rioja, 26006 Logroño, Spain; (R.J.-V.); (P.K.)
- Faculty of Finances and Management, WSB MERITO, University in Wroclaw, 53-609 Wrocław, Poland
| | - Sara Janczak
- Student Research Group, Department of Vascular, General and Transplantation Surgery, Wrocław Medical University, 50-556 Wrocław, Poland;
| | - Aleksander Mickiewicz
- Department of Emergency Medical Service, Wrocław Medical University, 51-616 Wrocław, Poland; (M.C.); (A.M.)
| | - Bartosz Uchmanowicz
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wrocław, Poland
| | - Stanisław Zieliński
- Department and Clinic of Anaesthesiology and Intensive Therapy, Faculty of Medicine, Wrocław Medical University, 50-556 Wrocław, Poland; (S.Z.); (M.Z.)
| | - Marzena Zielińska
- Department and Clinic of Anaesthesiology and Intensive Therapy, Faculty of Medicine, Wrocław Medical University, 50-556 Wrocław, Poland; (S.Z.); (M.Z.)
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14
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Trevellin E, Bettini S, Pilatone A, Vettor R, Milan G. Obesity, the Adipose Organ and Cancer in Humans: Association or Causation? Biomedicines 2023; 11:biomedicines11051319. [PMID: 37238992 DOI: 10.3390/biomedicines11051319] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Epidemiological observations, experimental studies and clinical data show that obesity is associated with a higher risk of developing different types of cancer; however, proof of a cause-effect relationship that meets the causality criteria is still lacking. Several data suggest that the adipose organ could be the protagonist in this crosstalk. In particular, the adipose tissue (AT) alterations occurring in obesity parallel some tumour behaviours, such as their theoretically unlimited expandability, infiltration capacity, angiogenesis regulation, local and systemic inflammation and changes to the immunometabolism and secretome. Moreover, AT and cancer share similar morpho-functional units which regulate tissue expansion: the adiponiche and tumour-niche, respectively. Through direct and indirect interactions involving different cellular types and molecular mechanisms, the obesity-altered adiponiche contributes to cancer development, progression, metastasis and chemoresistance. Moreover, modifications to the gut microbiome and circadian rhythm disruption also play important roles. Clinical studies clearly demonstrate that weight loss is associated with a decreased risk of developing obesity-related cancers, matching the reverse-causality criteria and providing a causality correlation between the two variables. Here, we provide an overview of the methodological, epidemiological and pathophysiological aspects, with a special focus on clinical implications for cancer risk and prognosis and potential therapeutic interventions.
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Affiliation(s)
- Elisabetta Trevellin
- Center for the Study and Integrated Treatment of Obesity (CeSTIO), Internal Medicine 3, Department of Medicine, University Hospital of Padova, 35128 Padova, Italy
| | - Silvia Bettini
- Center for the Study and Integrated Treatment of Obesity (CeSTIO), Internal Medicine 3, Department of Medicine, University Hospital of Padova, 35128 Padova, Italy
| | - Anna Pilatone
- Center for the Study and Integrated Treatment of Obesity (CeSTIO), Internal Medicine 3, Department of Medicine, University Hospital of Padova, 35128 Padova, Italy
| | - Roberto Vettor
- Center for the Study and Integrated Treatment of Obesity (CeSTIO), Internal Medicine 3, Department of Medicine, University Hospital of Padova, 35128 Padova, Italy
| | - Gabriella Milan
- Center for the Study and Integrated Treatment of Obesity (CeSTIO), Internal Medicine 3, Department of Medicine, University Hospital of Padova, 35128 Padova, Italy
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15
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Yang W, Guo G, Mao L, Hui Y, Wang X, Yu Z, Sun M, Li Y, Fan X, Cui B, Jiang K, Sun C. Comparison of the GLIM criteria with specific screening tool for diagnosing malnutrition in hospitalized patients with cirrhosis: A descriptive cross-sectional study. JPEN J Parenter Enteral Nutr 2023; 47:310-321. [PMID: 36128998 DOI: 10.1002/jpen.2452] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/04/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Wanting Yang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Gaoyue Guo
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Lihong Mao
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaoyu Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Zihan Yu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Mingyu Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Yifan Li
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaofei Fan
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Binxin Cui
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Kui Jiang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Tianjin, China.,Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
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16
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Kwon W, Lee SH, Yang JH, Choi KH, Park TK, Lee JM, Song YB, Hahn JY, Choi SH, Ahn CM, Ko YG, Yu CW, Jang WJ, Kim HJ, Kwon SU, Jeong JO, Park SD, Cho S, Bae JW, Gwon HC. Impact of the Obesity Paradox Between Sexes on In-Hospital Mortality in Cardiogenic Shock: A Retrospective Cohort Study. J Am Heart Assoc 2022; 11:e024143. [PMID: 35658518 PMCID: PMC9238714 DOI: 10.1161/jaha.121.024143] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Several studies have shown that obesity is associated with better outcomes in patients with cardiogenic shock (CS). Although this phenomenon, the “obesity paradox,” reportedly manifests differently based on sex in other disease entities, it has not yet been investigated in patients with CS. Methods and Results A total of 1227 patients with CS from the RESCUE (Retrospective and Prospective Observational Study to Investigate Clinical Outcomes and Efficacy of Left Ventricular Assist Device for Korean Patients With Cardiogenic Shock) registry in Korea were analyzed. The study population was classified into obese and nonobese groups according to Asian Pacific criteria (BMI ≥25.0 kg/m2 for obese). The clinical impact of obesity on in‐hospital mortality according to sex was analyzed using logistic regression analysis and restricted cubic spline curves. The in‐hospital mortality rate was significantly lower in obese men than nonobese men (34.2% versus 24.1%, respectively; P=0.004), while the difference was not significant in women (37.3% versus 35.8%, respectively; P=0.884). As a continuous variable, higher BMI showed a protective effect in men; conversely, BMI was not associated with clinical outcomes in women. Compared with patients with normal weight, obesity was associated with a decreased risk of in‐hospital death in men (multivariable‐adjusted odds ratio [OR], 0.63; CI, 0.43–0.92 [P=0.016]), but not in women (multivariable‐adjusted OR, 0.94; 95% CI, 0.55–1.61 [P=0.828]). The interaction P value for the association between BMI and sex was 0.023. Conclusions The obesity paradox exists and apparently occurs in men among patients with CS. The differential effect of BMI on in‐hospital mortality was observed according to sex. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02985008.
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Affiliation(s)
- Woochan Kwon
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Seung Hun Lee
- Division of Cardiology Department of Internal Medicine Chonnam National University Hospital Gwangju Republic of Korea
| | - Jeong Hoon Yang
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Ki Hong Choi
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Taek Kyu Park
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Joo Myung Lee
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Young Bin Song
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Joo-Yong Hahn
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Seung-Hyuk Choi
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Chul-Min Ahn
- Division of Cardiology Severance Cardiovascular HospitalYonsei University College of Medicine Seoul Republic of Korea
| | - Young-Guk Ko
- Division of Cardiology Severance Cardiovascular HospitalYonsei University College of Medicine Seoul Republic of Korea
| | - Cheol Woong Yu
- Division of Cardiology Department of Internal Medicine Korea University Anam Hospital Seoul Republic of Korea
| | - Woo Jin Jang
- Department of Cardiology Ewha Woman's University Seoul HospitalEhwa Woman's University School of Medicine Seoul Republic of Korea
| | - Hyun-Joong Kim
- Division of Cardiology Department of Medicine Konkuk University Medical Center Seoul Republic of Korea
| | - Sung Uk Kwon
- Division of Cardiology Department of Internal Medicine Ilsan Paik HospitalUniversity of Inje College of Medicine Seoul Republic of Korea
| | - Jin-Ok Jeong
- Division of Cardiology Department of Internal Medicine Chungnam National University Hospital Daejeon Republic of Korea
| | - Sang-Don Park
- Division of Cardiology Department of Medicine Inha University Hospital Incheon Republic of Korea
| | - Sungsoo Cho
- Division of Cardiovascular Medicine Department of Internal Medicine Dankook University HospitalDankook University College of Medicine Cheonan Korea
| | - Jang-Whan Bae
- Department of Internal Medicine Chungbuk National University HospitalChungbuk National UniversityCollege of Medicine Cheongju Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology Department of Medicine Heart Vascular Stroke InstituteSamsung Medical CenterSungkyunkwan University School of Medicine Seoul Republic of Korea
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17
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Natural History of Nonalcoholic Fatty Liver Disease With Normal Body Mass Index: A Population-Based Study. Clin Gastroenterol Hepatol 2022; 20:1374-1381.e6. [PMID: 34265444 PMCID: PMC8755855 DOI: 10.1016/j.cgh.2021.07.016] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/03/2021] [Accepted: 07/05/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The natural history of lean nonalcoholic fatty liver disease (NAFLD) is not well-understood. Consequently, patient counseling and disease management are limited. We aimed to compare the natural history of lean, overweight, and obese NAFLD in a U.S. population with long-term follow-up. METHODS All adults diagnosed with NAFLD in Olmsted County, MN between 1996 and 2016 were identified, and all subsequent medical events were ascertained using a medical record linkage system. Subjects were divided on the basis of body mass index (BMI) at NAFLD diagnosis into 3 groups: normal, overweight, and obese. The probability to develop cirrhosis, decompensation, malignancies, cardiovascular events, or death among the 3 groups was estimated by using the Aalen-Johansen method, treating death as a competing risk. The impact of BMI categories on these outcomes was explored by using Cox proportional hazards regression analysis. RESULTS A total of 4834 NAFLD individuals were identified: 414 normal BMI, 1189 overweight, and 3231 obese. Normal BMI NAFLD individuals were characterized by a higher proportion of women (66% vs 47%) and lower prevalence of metabolic comorbidities than the other 2 groups. In reference to obese, those with normal BMI NAFLD had a nonsignificant trend toward lower risk of cirrhosis (hazard ratio [HR], 0.33, 95% confidence interval [CI], 0.1-1.05). There were no significant differences in the risk of decompensation (HR, 0.79; 95% CI, 0.11-5.79), cardiovascular events (HR, 1.05; 95% CI, 0.73-1.51), or malignancy (HR, 0.87; 95% CI, 0.51-1.48). Compared with obese, normal BMI NAFLD had higher risk of all-cause mortality (HR, 1.96; 95% CI, 1.52-2.51). CONCLUSIONS NAFLD with normal BMI is associated with a healthier metabolic profile and possibly a lower risk of liver disease progression but similar risk of cardiovascular disease and malignancy than obese NAFLD.
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de Miguel-Diez J, Jimenez-Garcia R, Hernandez-Barrera V, de Miguel-Yanes JM, Carabantes-Alarcon D, Zamorano-Leon JJ, Lopez-de-Andres A. Obesity survival paradox in patients hospitalized with community-acquired pneumonia. Assessing sex-differences in a population-based cohort study. Eur J Intern Med 2022; 98:98-104. [PMID: 35067415 DOI: 10.1016/j.ejim.2022.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/23/2021] [Accepted: 01/17/2022] [Indexed: 12/21/2022]
Abstract
AIM To assess the effect of obesity status (no obesity/obesity/ morbid obesity) on hospital outcomes (length of hospital stay [LOHS] and in-hospital mortality [IHM]), among patients hospitalized with community-acquired pneumonia (CAP) and according to sex. METHODS We conducted a retrospective cohort study based on national hospital discharge data of all subjects aged≥ 18 years hospitalized with CAP in Spain from 2016 to 2019. RESULTS We identified 519,750 hospital discharges with CAP. The prevalence of obesity was 6.38% and 1.78%. for morbid obesity. The mean age was higher for patients without obesity followed by those with obesity and morbid obesity (74.61, 72.5 and 70.2 years respectively; p<0.001). The mean number of comorbidities was similar for patients with obesity and morbid obesity (2.30 and 2.29) and significantly higher than for non-obese individuals (2.10). The crude IHM was higher among the non-obese patients (12.71%) followed by those with morbid obesity (8.56%) and obesity (7.72%), without finding differences between men and women. Among men, after multivariable logistic regression analysis, the probability of dying in the hospital was significantly lower for those with obesity (Adjusted-OR 0.59;95%CI 0.55-0.63) and morbid obesity (Adjusted-OR 0.62;95%CI 0.54-0.71) compared with non-obese. The protective effect of obesity (Adjusted-OR 0.71;95%CI 0.67-0.75) and morbid obesity (Adjusted OR 0.73;95%CI 0.66-0.8) was also observed among women. CONCLUSIONS Obese and obesity morbid patients with CAP have a lower risk of IHM than non-obese patients, without sex differences in this association. These data confirm the existence of the obesity paradox in this patient population.
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Affiliation(s)
- Javier de Miguel-Diez
- Respiratory Care Department. Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid. Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM). Madrid, Spain
| | - Rodrigo Jimenez-Garcia
- Department of Public Health & Maternal and Child Health. Faculty of Medicine. Universidad Complutense de Madrid, Madrid, Spain.
| | - Valentin Hernandez-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit. Health Sciences Faculty, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Jose M de Miguel-Yanes
- Internal Medicine Department. Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid. Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - David Carabantes-Alarcon
- Department of Public Health & Maternal and Child Health. Faculty of Medicine. Universidad Complutense de Madrid, Madrid, Spain
| | - Jose J Zamorano-Leon
- Department of Public Health & Maternal and Child Health. Faculty of Medicine. Universidad Complutense de Madrid, Madrid, Spain
| | - Ana Lopez-de-Andres
- Department of Public Health & Maternal and Child Health. Faculty of Medicine. Universidad Complutense de Madrid, Madrid, Spain
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Lee DU, Fan GH, Hastie DJ, Addonizio EA, Prakasam VN, Ahern RR, Seog KJ, Karagozian R. The Impact of Malnutrition on the Hospital and Infectious Outcomes of Patients Admitted With Alcoholic Hepatitis: 2011 to 2017 Analysis of US Hospitals. J Clin Gastroenterol 2022; 56:349-359. [PMID: 33769393 DOI: 10.1097/mcg.0000000000001528] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/06/2021] [Indexed: 01/13/2023]
Abstract
GOALS We specifically evaluate the effect of malnutrition on the infection risks of patients admitted with alcoholic hepatitis using a national registry of hospitalized patients in the United States. BACKGROUND Malnutrition is a common manifestation of alcoholic hepatitis that affects patient outcomes. STUDY 2011 to 2017 National Inpatient Sample was used to isolated patients with alcoholic hepatitis, stratified using malnutrition (protein-calorie malnutrition, sarcopenia, and weight loss/cachexia) and matched using age, gender, and race with 1:1 nearest neighbor matching method. Endpoints included mortality and infectious endpoints. RESULTS After matching, there were 10,520 with malnutrition and 10,520 malnutrition-absent controls. Mortality was higher in the malnutrition cohort [5.02 vs. 2.29%, P<0.001, odds ratio (OR): 2.25, 95% confidence interval (CI): 1.93-2.63], as were sepsis (14.2 vs. 5.46, P<0.001, OR: 2.87, 95% CI: 2.60-3.18), pneumonia (10.9 vs. 4.63%, P<0.001, OR: 2.51, 95% CI: 2.25-2.81), urinary tract infection (14.8 vs. 9.01%, P<0.001, OR: 1.76, 95% CI: 1.61-1.91), cellulitis (3.17 vs. 2.18%, P<0.001, OR: 1.47, 95% CI: 1.24-1.74), cholangitis (0.52 vs. 0.20%, P<0.001, OR: 2.63, 95% CI: 1.59-4.35), and Clostridium difficile infection (1.67 vs. 0.91%, P<0.001, OR: 1.85, 95% CI: 1.44-2.37). In multivariate models, malnutrition was associated with mortality [P<0.001, adjusted odds ratio (aOR): 1.61, 95% CI: 1.37-1.90] and infectious endpoints: sepsis (P<0.001, aOR: 2.42, 95% CI: 2.18-2.69), pneumonia (P<0.001, aOR: 2.19, 95% CI: 1.96-2.46), urinary tract infection (P<0.001, aOR: 1.68, 95% CI: 1.53-1.84), cellulitis (P<0.001, aOR: 1.46, 95% CI: 1.22-1.74), cholangitis (P=0.002, aOR: 2.27, 95% CI: 1.36-3.80), and C. difficile infection (P<0.001, aOR: 1.89, 95% CI: 1.46-2.44). CONCLUSION This study shows the presence of malnutrition is an independent risk factor of mortality and local/systemic infections in patients admitted with alcoholic hepatitis.
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Affiliation(s)
- David U Lee
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Washington Street, Boston, MA
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Bettini S, Serra R, Fabris R, Dal Prà C, Favaretto F, Dassie F, Duso C, Vettor R, Busetto L. Association of obstructive sleep apnea with non-alcoholic fatty liver disease in patients with obesity: an observational study. Eat Weight Disord 2022; 27:335-343. [PMID: 33811619 PMCID: PMC8019078 DOI: 10.1007/s40519-021-01182-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Obstructive Sleep Apnea (OSA) is associated with the presence and severity of Non-Alcoholic Fatty Liver Disease (NAFLD). We aimed to investigate the relationship between the severity of OSA and NAFLD and to recognize a polysomnographic parameter correlated with progression of fibrosis, determined by a non-invasive score of liver fibrosis, FIBrosis-4 index (FIB-4), in patients affected by severe obesity and OSA. METHODS We enrolled 334 patients (Body Mass Index, BMI 44.78 ± 8.99 kg/m2), divided into classes according to severity of OSA evaluated with Apnea Hypopnea Index (AHI): OSAS 0 or absent (17%), mild OSA (26%), moderate OSA (20%), severe OSAS (37%). We studied anthropometric, polysomnographic, biochemical data and FIB-4. A multiple regression model was computed to identify a polysomnographic independent predictor of FIB-4 among those parameters previously simple correlated with FIB-4. RESULTS The severity of OSA was associated with a decrease in High-Density Lipoprotein-cholesterol (HDL) and an increase in BMI, triglycerides, Homeostasis model assessment insulin-resistance index (HOMA), transaminases and FIB-4. FIB-4 correlated with sex, age, BMI, AHI, mean percentage oxyhaemoglobin (meanSaO2%), number of desaturations, platelets, transaminases, HDL, triglycerides and HOMA. The only variables independently related to FIB-4 were sex, BMI, triglycerides and meanSpO2 (r = 0.47, AdjRsqr = 0.197). CONCLUSION MeanSpO2% represented an independent determinant for the worsening of FIB-4 in patients with severe obesity and OSA. Hence, it could hypothesize a clinical role of meanSaO2% in recognizing patients with obesity and OSA and higher risk of developing advanced fibrosis and, thus, to undergo further investigation. LEVEL III Evidence obtained from well-designed cohort analytic studies.
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Affiliation(s)
- Silvia Bettini
- Department of Medicine, Internal Medicine 3, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
| | - Roberto Serra
- Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Padova, Italy
| | - Roberto Fabris
- Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Padova, Italy
| | - Chiara Dal Prà
- Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Padova, Italy
| | - Francesca Favaretto
- Department of Medicine, Internal Medicine 3, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.,Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Padova, Italy
| | - Francesca Dassie
- Department of Medicine, Internal Medicine 3, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Claudio Duso
- Department of Medicine, Internal Medicine 3, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Roberto Vettor
- Department of Medicine, Internal Medicine 3, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.,Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Padova, Italy
| | - Luca Busetto
- Department of Medicine, Internal Medicine 3, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.,Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Padova, Italy
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Ma Z, Li S, Lin X. Body mass index, blood glucose, and mortality in patients with ischemic stroke in the intensive care unit: A retrospective cohort study. Front Neurosci 2022; 16:946397. [PMID: 36340767 PMCID: PMC9629862 DOI: 10.3389/fnins.2022.946397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/03/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Excessive BMI was associated with lower mortality after stroke. However, some believed that excessive BMI can lead to a poor prognosis because of some physiological mechanism, such as glucose metabolism disorder. Therefore, this study aims to discuss the association between mortality, BMI, and blood glucose. MATERIALS AND METHODS This was a retrospective observational study and all data were extracted from the Medical Information Mart for Intensive Care III database. The exposure was BMI classified into the normal weight group and the excessive weight group. The outcome concluded 30-day, 90-day, and 1-year mortality. The association between two groups and mortality was elucidated by Cox regression models, propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). The underlying effect of blood glucose on the "obesity paradox" was analyzed by causal mediation analysis. RESULTS According to Cox regression models, a significant beneficial effect of excessive BMI in terms of mortality was observed: 30-day mortality (HR 0.57, 95% CI 0.35-0.90, P = 0.017), 90-day mortality (HR 0.53, 95% CI 0.36-0.78, P = 0.001), and 1-year mortality (HR 0.65, 95% CI 0.46-0.91, P = 0.013). After PSM and IPTW, we got a similar conclusion. The causal mediation analysis showed that the protective effect of excessive BMI on 30-day mortality reduced with the increase of blood glucose. CONCLUSION For ischemic stroke patients in the Intensive Care Unit, those with excessive BMI are associated with both lower short-term mortality and lower long-term mortality, while the protective effect on 30-day mortality weakened accompanied by the increase of blood glucose.
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Affiliation(s)
- Zisheng Ma
- Department of Neurology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | | | - Xinjiang Lin
- Department of Neurology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
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Chang J, Höfer P, Böhling N, Lingohr P, Manekeller S, Kalff JC, Dohmen J, Kaczmarek DJ, Jansen C, Meyer C, Strassburg CP, Trebicka J, Praktiknjo M. Pre-operative TIPS may reduce post-operative ACLF occurrence. JHEP REPORTS : INNOVATION IN HEPATOLOGY 2022; 4:100442. [PMID: 35198929 PMCID: PMC8844300 DOI: 10.1016/j.jhepr.2022.100442] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/10/2021] [Accepted: 12/28/2021] [Indexed: 11/25/2022]
Abstract
Background & Aims Acute-on-chronic liver failure (ACLF) is a syndrome associated with organ failure and high short-term mortality. Recently, the role of surgery as a precipitating event for ACLF has been characterised. However, the impact of preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement on ACLF development in patients with cirrhosis undergoing surgery has not been investigated yet. Methods A total of 926 patients (363 with cirrhosis undergoing surgery and 563 patients with TIPS) were screened. Forty-five patients with preoperative TIPS (TIPS group) were 1:1 propensity matched to patients without preoperative TIPS (no-TIPS group). The primary endpoint was the development of ACLF within 28 and 90 days after surgery. The secondary endpoint was 1-year mortality. Results were confirmed by a differently 1:2 matched cohort (n = 176). Results Patients in the no-TIPS group had significantly higher rates of ACLF within 28 days (29 vs. 9%; p = 0.016) and 90 days (33 vs. 13%; p = 0.020) after surgery as well as significantly higher 1-year mortality (38 vs. 18%; p = 0.023) compared with those in the TIPS group. Surgery without preoperative TIPS and Chronic Liver Failure Consortium–Acute Decompensation (CLIF-C AD) score were independent predictors for 28- and 90-day ACLF development and 1-year mortality after surgery, especially in patients undergoing visceral surgery. In the no-TIPS group, a CLIF-C AD score of >45 could be identified as cut-off for patients at risk for postoperative ACLF development benefiting from TIPS. Conclusions This study suggests that preoperative TIPS may result in lower rates of postoperative ACLF development especially in patients undergoing visceral surgery and with a CLIF-C AD score above 45. Lay summary Acute-on-chronic liver failure (ACLF) is a syndrome that is associated with high short-term mortality. Surgical procedures are a known precipitating event for ACLF. This study investigates the role of preoperative insertion of a transjugular intrahepatic portosystemic shunt (TIPS) on postoperative mortality and ACLF development. Patients with TIPS insertion before a surgical procedure exhibit improved postoperative survival and lower rates of postoperative ACLF, especially in patients undergoing visceral surgery and with a high CLIF-C AD prognostic score. Thus, this study suggests preoperative TIPS insertion in those high-risk patients.
This study investigates the impact of preoperative TIPS on postsurgical ACLF. Patients with preoperative TIPS, especially before visceral surgery, develop significantly lower rates of ACLF. Preoperative TIPS is associated with improved postsurgical survival. CLIF-C AD score >45 can be used as cut-off for patients at risk for postsurgical ACLF. Selected patients might benefit from preoperative TIPS insertion.
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Liver disease in obesity and underweight: the two sides of the coin. A narrative review. Eat Weight Disord 2021; 26:2097-2107. [PMID: 33150534 DOI: 10.1007/s40519-020-01060-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 10/16/2020] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Malnutrition, whether characterized by not enough or too much nutrient intake, is detrimental to the liver. We herein provide a narrative literature revision relative to hepatic disease occurrence in over or undernourished subjects, to shed light on the paradox where both sides of malnutrition lead to similar liver dysfunction and fat accumulation. METHODS Medline, EMBASE, and Cochrane Library were searched for publications up to July 2020. Articles discussing the association between both chronic and acute liver pathology and malnutrition were evaluated together with studies reporting the dietary intake in subjects affected by malnutrition. RESULTS The association between overnutrition and non-alcoholic fatty liver disease (NAFLD) is well recognized, as the beneficial effects of calorie restriction and very low carbohydrate diets. Conversely, the link between undernutrition and liver injury is more complex and less understood. In developing countries, early exposure to nutrient deficiency leads to marasmus and kwashiorkor, accompanied by fatty liver, whereas in developed countries anorexia nervosa is a more common form of undernutrition, associated with liver injury. Weight gain in undernutrition is associated with liver function improvement, whereas no study on the impact of macronutrient distribution is available. We hypothesized a role for very low carbohydrate diets in the management of undernutrition derived liver pathology, in addition to the established one in overnutrition-related NAFLD. CONCLUSIONS Further studies are warranted to update the knowledge regarding undernutrition-related liver disease, and a specific interest should be paid to macronutrient distribution both in the context of refeeding and relative to its role in the development of hepatic complications of anorexia nervosa. LEVEL OF EVIDENCE Narrative review, Level V.
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John BV, Khakoo NS, Schwartz KB, Aitchenson G, Levy C, Dahman B, Deng Y, Goldberg DS, Martin P, Kaplan DE, Taddei TH. Ursodeoxycholic Acid Response Is Associated With Reduced Mortality in Primary Biliary Cholangitis With Compensated Cirrhosis. Am J Gastroenterol 2021; 116:1913-1923. [PMID: 33989225 PMCID: PMC8410631 DOI: 10.14309/ajg.0000000000001280] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 03/12/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Patients with cirrhosis and men have been under-represented in most studies examining the clinical benefit of response to ursodeoxycholic acid (UDCA) in primary biliary cholangitis (PBC). The aim of this study was to study the association of UDCA response and liver-related death or transplantation, hepatic decompensation, and hepatocellular carcinoma (HCC) in patients with PBC cirrhosis. METHODS We conducted a retrospective cohort study of veterans, predominantly men, with PBC and compensated cirrhosis to assess the association of UDCA response with the development of all-cause and liver-related mortality or transplantation, hepatic decompensation, and HCC using competing risk time-updating Cox proportional hazards models. RESULTS We identified 501 subjects with PBC and compensated cirrhosis, including 287 UDCA responders (1,692.8 patient-years [PY] of follow-up) and 214 partial responders (838.9 PY of follow-up). The unadjusted rates of hepatic decompensation (3.8 vs 7.9 per 100 PY, P < 0.0001) and liver-related death or transplantation (3.7 vs 6.2 per 100 PY, P < 0.0001) were lower in UDCA responders compared with partial responders. UDCA response was associated with a lower risk of hepatic decompensation (subhazard ratio [sHR] 0.54, 95% confidence interval [CI] 0.31-0.95, P = 0.03), death from any cause or transplantation (adjusted hazard ratio 0.49, 95% CI 0.33-0.72, P = 0.0002), and liver-related death or transplantation (sHR 0.40, 95% CI 0.24-0.67, P = 0.0004), but not HCC (sHR 0.39, 95% CI 0.60-2.55, P = 0.32). In a sensitivity analysis, the presence of portal hypertension was associated with the highest UDCA-associated effect. DISCUSSION UDCA response is associated with a reduction in decompensation, all-cause, and liver-related death or transplantation in a cohort of predominantly male patients with cirrhosis, with the highest benefit in patients with portal hypertension.
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Affiliation(s)
- Binu V John
- Division of Hepatology, Bruce W Carter VA Medical Center, Miami, FL
| | | | - Kaley B Schwartz
- Division of Hepatology, Bruce W Carter VA Medical Center, Miami, FL
| | | | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
- Division of Gastroenterology and Hepatology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Tamar H. Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT
- Division of Gastroenterology and Hepatology, VA Connecticut Healthcare System, West Haven, CT
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Yin Y, Li Y, Shao L, Yuan S, Liu B, Lin S, Yang Y, Tang S, Meng F, Wu Y, Chen Y, Li B, Zhu Q, Qi X. Effect of Body Mass Index on the Prognosis of Liver Cirrhosis. Front Nutr 2021; 8:700132. [PMID: 34490322 PMCID: PMC8417598 DOI: 10.3389/fnut.2021.700132] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/23/2021] [Indexed: 02/05/2023] Open
Abstract
Objective: At present, the association of body mass index (BMI) with the prognosis of liver cirrhosis is controversial. Our retrospective study aimed to evaluate the impact of BMI on the outcome of liver cirrhosis. Methods: In the first part, long-term death was evaluated in 436 patients with cirrhosis and without malignancy from our prospectively established single-center database. In the second part, in-hospital death was evaluated in 379 patients with cirrhosis and with acute gastrointestinal bleeding (AGIB) from our retrospective multicenter study. BMI was calculated and categorized as underweight (BMI <18.5 kg/m2), normal weight (18.5 ≤ BMI < 23.0 kg/m2), and overweight/obese (BMI ≥ 23.0 kg/m2). Results: In the first part, Kaplan-Meier curve analyses demonstrated a significantly higher cumulative survival rate in the overweight/obese group than the normal weight group (p = 0.047). Cox regression analyses demonstrated that overweight/obesity was significantly associated with decreased long-term mortality compared with the normal weight group [hazard ratio (HR) = 0.635; 95% CI: 0.405-0.998; p = 0.049] but not an independent predictor after adjusting for age, gender, and Child-Pugh score (HR = 0.758; 95%CI: 0.479-1.199; p = 0.236). In the second part, Kaplan-Meier curve analyses demonstrated no significant difference in the cumulative survival rate between the overweight/obese and the normal weight groups (p = 0.094). Cox regression analyses also demonstrated that overweight/obesity was not significantly associated with in-hospital mortality compared with normal weight group (HR = 0.349; 95%CI: 0.096-1.269; p = 0.110). In both of the two parts, the Kaplan-Meier curve analyses demonstrated no significant difference in the cumulative survival rate between underweight and normal weight groups. Conclusion: Overweight/obesity is modestly associated with long-term survival in patients with cirrhosis but not an independent prognostic predictor. There is little effect of overweight/obesity on the short-term survival of patients with cirrhosis and with AGIB.
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Affiliation(s)
- Yue Yin
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
| | - Yiling Li
- Department of Gastroenterology, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Lichun Shao
- Department of Gastroenterology, Air Force Hospital of Northern Theater Command, Shenyang, China
| | - Shanshan Yuan
- Department of Gastroenterology, Xi'an Central Hospital, Xi'an, China
| | - Bang Liu
- Department of Hepatobiliary Disease, 900 Hospital of the Joint Logistics Team (formerly called Fuzhou General Hospital), Fuzhou, China
| | - Su Lin
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yida Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Shanhong Tang
- Department of Gastroenterology, General Hospital of Western Theater Command, Chengdu, China
| | - Fanping Meng
- Department of Biological Therapy, Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Yunhai Wu
- Department of Critical Care Medicine, Sixth People's Hospital of Shenyang, Shenyang, China
| | - Yu Chen
- Difficult and Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Bimin Li
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qiang Zhu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), Shenyang, China
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Choi C, Lennon RJ, Choi DH, Serafim LP, Allen AM, Kamath PS, Shah VH, de Moraes AG, Simonetto DA. Relationship Between Body Mass Index and Survival Among Critically Ill Patients With Cirrhosis. J Intensive Care Med 2021; 37:817-824. [PMID: 34219539 DOI: 10.1177/08850666211029827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Obesity paradox is a phenomenon in which obesity increases the risk of obesity-related chronic diseases but paradoxically is associated with improved survival among obese patients with these diagnoses. OBJECTIVES The aim of this study was to explore the obesity paradox among critically ill patients with cirrhosis admitted to the Intensive Care Unit. METHODS A retrospective cohort of 1,143 consecutive patients with cirrhosis admitted to the ICU between January of 2006 and December of 2015 was analyzed. Primary outcome of interest was in-hospital mortality with secondary end points including ICU and short-term mortality at 30 days post ICU admission. RESULTS Logistic regression with generalized additive models was used, controlling for clinically relevant and statistically significant factors to determine the adjusted relationship between body mass index (BMI) and ICU, post-ICU in-hospital, and 30 day mortality following ICU discharge. ICU and hospital length of stay was similar across all BMI classes. Adjusted ICU mortality was also similar when stratified by BMI. However, a significant reduction in post-ICU hospital mortality was observed in class I and II obese patients with cirrhosis (BMI 30-39.9 kg/m2) compared to normal BMI (OR = 0.41; 95% CI, 0.20 to 0.83; P = 0.014). Similarly, overweight (BMI 25-29.9 kg/m2) and class I and II obese patients with cirrhosis had significantly lower 30-day mortality following ICU discharge (OR = 0.52, 95% CI 0.31 to 0.87; P = 0.014; OR = 0.50, 95% CI 0.29 to 0.86; P = 0.012, respectively) compared to those with normal BMI. CONCLUSION The signal of obesity paradox is suggested among critically ill patients with cirrhosis.
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Affiliation(s)
- Chansong Choi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ryan J Lennon
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Dae Hee Choi
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon, Gangwon, Republic of Korea
| | - Laura Piccolo Serafim
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Alina M Allen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alice Gallo de Moraes
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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New model predicting gastroesophageal varices and variceal hemorrhage in patients with chronic liver disease. Ann Hepatol 2021; 21:100275. [PMID: 33075577 DOI: 10.1016/j.aohep.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/05/2020] [Indexed: 02/04/2023]
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Impact of visceral fat accumulation on the prognosis of patients with cirrhosis. Clin Nutr ESPEN 2021; 42:354-360. [PMID: 33745605 DOI: 10.1016/j.clnesp.2021.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/04/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS The impact of obesity, evaluated using body mass index (BMI), on mortality in patients with cirrhosis is controversial. The prognostic impact of visceral fat accumulation, which is recommended as an indicator of obesity-related mortality, is still unknown. This study aimed to clarify the impact of visceral fat accumulation on mortality in patients with cirrhosis. METHODS A total of 335 cirrhotic patients without hepatocellular carcinoma were retrospectively evaluated. The impact of obesity, defined as a visceral fat area ≥100 cm2 at the umbilical level or BMI ≥25 kg/m2 on mortality, was evaluated using competing risk analysis. RESULTS Of 355 patients, visceral fat accumulation was seen in 147 patients. During the observation period (1340 ± 980 days), 84 patients died, and 17 received liver transplantation. Visceral fat accumulation was not found to be associated with mortality (hazard ratio [HR] 1.423, P = 0.180) in any of the patients. After stratification of the patients, visceral fat accumulation was observed to be associated with a poor prognosis in patients with skeletal muscle depletion (HR 3.804, P = 0.003), but not in those without (HR 1.147, P = 0.660). On the other hand, obesity defined by BMI ≥25 kg/m2 was not found to be associated with mortality in patients with (HR 0.341, P = 0.390) or without skeletal muscle depletion (HR 1.227, P = 0.500). CONCLUSIONS Visceral fat accumulation is a useful index for evaluating obesity and aggravates mortality in cirrhotic patients with skeletal muscle depletion, but not in those without.
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Nishikawa H, Enomoto H, Nishiguchi S, Iijima H. Sarcopenic Obesity in Liver Cirrhosis: Possible Mechanism and Clinical Impact. Int J Mol Sci 2021; 22:1917. [PMID: 33671926 PMCID: PMC7919019 DOI: 10.3390/ijms22041917] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 02/07/2023] Open
Abstract
The picture of chronic liver diseases (CLDs) has changed considerably in recent years. One of them is the increase of non-alcoholic fatty liver disease. More and more CLD patients, even those with liver cirrhosis (LC), tend to be presenting with obesity these days. The annual rate of muscle loss increases with worsening liver reserve, and thus LC patients are more likely to complicate with sarcopenia. LC is also characterized by protein-energy malnutrition (PEM). Since the PEM in LC can be invariable, the patients probably present with sarcopenic obesity (Sa-O), which involves both sarcopenia and obesity. Currently, there is no mention of Sa-O in the guidelines; however, the rapidly increasing prevalence and poorer clinical consequences of Sa-O are recognized as an important public health problem, and the diagnostic value of Sa-O is expected to increase in the future. Sa-O involves a complex interplay of physiological mechanisms, including increased inflammatory cytokines, oxidative stress, insulin resistance, hormonal disorders, and decline of physical activity. The pathogenesis of Sa-O in LC is diverse, with a lot of perturbations in the muscle-liver-adipose tissue axis. Here, we overview the current knowledge of Sa-O, especially focusing on LC.
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Affiliation(s)
- Hiroki Nishikawa
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan; (H.E.); (H.I.)
- Center for Clinical Research and Education, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan
| | - Hirayuki Enomoto
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan; (H.E.); (H.I.)
| | - Shuhei Nishiguchi
- Department of Internal Medicine, Kano General Hospital, Osaka 531-0041, Japan;
| | - Hiroko Iijima
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, Japan; (H.E.); (H.I.)
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Lee DU, Fan GH, Ahern RR, Karagozian R. The effect of malnutrition on the infectious outcomes of hospitalized patients with cirrhosis: analysis of the 2011-2017 hospital data. Eur J Gastroenterol Hepatol 2021; 32:269-278. [PMID: 33252419 DOI: 10.1097/meg.0000000000001991] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In patients with cirrhosis, there is a clinical concern that the development of protein-calorie malnutrition will affect the immune system and predispose these patients to increased infectious outcomes. AIMS In this study, we evaluate the effects of malnutrition on the infectious outcomes of patients admitted with cirrhosis. MATERIALS AND METHODS This study used the 2011-2017 National Inpatient Sample to identify patients with cirrhosis. These patients were stratified using malnutrition (protein-calorie malnutrition, cachexia, and sarcopenia) and matched using age, gender, and race with 1:1 nearest neighbor matching method. The endpoints included mortality and infectious outcomes. RESULTS After matching, there were 96 842 malnutrition-present cohort and equal number of controls. In univariate analysis, the malnutrition cohort had higher hospital mortality [10.40 vs. 5.04% P < 0.01, odds ratio (OR) 2.18, 95% confidence interval (CI) 2.11-2.26]. In multivariate models, malnutrition was associated with increased mortality [P < 0.01, adjusted odds ratio (aOR) 1.32, 95% CI 1.27-1.37] and infectious outcomes, including sepsis (P < 0.01, aOR 1.94, 95% CI 1.89-2.00), pneumonia (P < 0.01, aOR 1.68, 95% CI 1.63-1.73), UTI (P < 0.01, aOR 1.39, 95% CI 1.35-1.43), cellulitis (P < 0.01, aOR 1.09, 95% CI 1.05-1.13), cholangitis (P < 0.01, aOR 1.39, 95% CI 1.26-1.55), and clostridium difficile (P < 0.01, aOR 2.11, 95% CI 1.92-2.31). CONCLUSION The results of this study indicate that malnutrition is an independent risk factor of hospital mortality and local/systemic infections in patients admitted with cirrhosis.
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Affiliation(s)
- David Uihwan Lee
- Division of Gastroenterology, Liver Center, Tufts Medical Center, 800 Washington Street, Boston, Massachusetts, USA
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Mahmud N, Fricker Z, Hubbard RA, Ioannou GN, Lewis JD, Taddei TH, Rothstein KD, Serper M, Goldberg DS, Kaplan DE. Risk Prediction Models for Post-Operative Mortality in Patients With Cirrhosis. Hepatology 2021; 73:204-218. [PMID: 32939786 PMCID: PMC7902392 DOI: 10.1002/hep.31558] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/24/2020] [Accepted: 08/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Patients with cirrhosis are at increased risk of postoperative mortality. Currently available tools to predict postoperative risk are suboptimally calibrated and do not account for surgery type. Our objective was to use population-level data to derive and internally validate cirrhosis surgical risk models. APPROACH AND RESULTS We conducted a retrospective cohort study using data from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) cohort, which contains granular data on patients with cirrhosis from 128 U.S. medical centers, merged with the Veterans Affairs Surgical Quality Improvement Program (VASQIP) to identify surgical procedures. We categorized surgeries as abdominal wall, vascular, abdominal, cardiac, chest, or orthopedic and used multivariable logistic regression to model 30-, 90-, and 180-day postoperative mortality (VOCAL-Penn models). We compared model discrimination and calibration of VOCAL-Penn to the Mayo Risk Score (MRS), Model for End-Stage Liver Disease (MELD), Model for End-Stage Liver Disease-Sodium MELD-Na, and Child-Turcotte-Pugh (CTP) scores. We identified 4,712 surgical procedures in 3,785 patients with cirrhosis. The VOCAL-Penn models were derived and internally validated with excellent discrimination (30-day postoperative mortality C-statistic = 0.859; 95% confidence interval [CI], 0.809-0.909). Predictors included age, preoperative albumin, platelet count, bilirubin, surgery category, emergency indication, fatty liver disease, American Society of Anesthesiologists classification, and obesity. Model performance was superior to MELD, MELD-Na, CTP, and MRS at all time points (e.g., 30-day postoperative mortality C-statistic for MRS = 0.766; 95% CI, 0.676-0.855) in terms of discrimination and calibration. CONCLUSIONS The VOCAL-Penn models substantially improve postoperative mortality predictions in patients with cirrhosis. These models may be applied in practice to improve preoperative risk stratification and optimize patient selection for surgical procedures (www.vocalpennscore.com).
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Zachary Fricker
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Rebecca A. Hubbard
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - George N. Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA
| | - James D. Lewis
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Kenneth D. Rothstein
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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Fricker ZP, Mukthinuthalapati VVPK, Akinyeye S, Chalasani N, Attar BM, Balakrishnan M, Ghabril M, Long MT. MELD-Na Is More Strongly Associated with Risk of Infection and Outcomes Than Other Characteristics of Patients with Cirrhosis. Dig Dis Sci 2021; 66:247-256. [PMID: 32100160 PMCID: PMC7222109 DOI: 10.1007/s10620-020-06164-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 02/20/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS The nature and outcomes of infection among patients with cirrhosis in safety-net hospitals are not well described. We aimed to characterize the rate of and risk factors for infection, both present on admission and nosocomial, in this unique population. We hypothesized that infections would be associated with adverse outcomes such as short-term mortality. METHODS We used descriptive statistics to characterize infections within a retrospective cohort characterized previously. We used multivariable logistic regression models to assess potential risk factors for infection and associations with key outcomes such as short-term mortality and length of stay. RESULTS The study cohort of 1112 patients included 33% women with a mean age of 56 ± 10 years. Infections were common (20%), with respiratory and urinary tract infections the most frequent. We did not observe a difference in the incidence of infection on admission based on patient demographic factors such as race/ethnicity or estimated household income. Infections on admission were associated with greater short-term mortality (12% vs 4% in-hospital and 14% vs 7% 30-day), longer length of stay (6 vs 3 days), intensive care unit admission (28% vs 18%), and acute-on-chronic liver failure (10% vs 2%) (p < 0.01 for all). Nosocomial infections were relatively uncommon (4%), but more frequent among patients admitted to the intensive care unit. Antibiotic resistance was common (38%), but not associated with negative outcomes. CONCLUSION We did not identify demographic risk factors for infection, but did confirm its morbid effect among patients with cirrhosis in safety-net hospitals.
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Affiliation(s)
- Zachary P. Fricker
- grid.38142.3c000000041936754XDivision of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, 8th Floor, Boston, MA 02215 USA
| | - V. V. Pavan Kedar Mukthinuthalapati
- grid.257413.60000 0001 2287 3919Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN USA ,grid.428291.4Division of Gastroenterology, Cook County Health, Chicago, IL USA
| | - Samuel Akinyeye
- grid.412332.50000 0001 1545 0811Division of Gastroenterology, Hepatology and Nutrition, Ohio State University Medical Center, Columbus, OH USA
| | - Naga Chalasani
- grid.257413.60000 0001 2287 3919Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN USA
| | - Bashar M. Attar
- grid.428291.4Division of Gastroenterology, Cook County Health, Chicago, IL USA
| | - Maya Balakrishnan
- grid.39382.330000 0001 2160 926XSection of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX USA
| | - Marwan Ghabril
- grid.257413.60000 0001 2287 3919Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN USA
| | - Michelle T. Long
- grid.189504.10000 0004 1936 7558Section of Gastroenterology, Evans Department of Medicine, Boston University School of Medicine, Boston, MA USA
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Ebadi M, Bhanji RA, Tandon P, Mazurak V, Baracos VE, Montano-Loza AJ. Review article: prognostic significance of body composition abnormalities in patients with cirrhosis. Aliment Pharmacol Ther 2020; 52:600-618. [PMID: 32621329 DOI: 10.1111/apt.15927] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/17/2020] [Accepted: 06/09/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recent advances in evaluation of body composition show body mass index to be inadequate in differentiating between body compartments in cirrhosis. Given the limitations of body mass index, body composition evaluation using computed tomography has been increasingly used as a non-invasive clinical tool with prognostic value. Another factor influencing prognosis includes sex-specific differences in body composition that are seen in cirrhosis. AIM To review current knowledge regarding the frequency and clinical implications of abnormal body composition features in cirrhosis. METHODS We searched PubMed database and limited the literature search to full-text papers published in English. Studies using inappropriate landmarks or demarcation of body composition components on computed tomography images were eliminated. RESULTS Sarcopenia is a well established factor affecting morbidity and mortality in cirrhosis. Other important body composition components that have been overlooked thus far include subcutaneous adipose tissue and visceral adipose tissue. Female patients with cirrhosis and low subcutaneous adiposity have a higher risk of mortality, whereas male patients with high visceral adiposity have a higher risk of hepatocellular carcinoma and recurrence following liver transplantation. Increased adipose tissue radiodensity has been associated with risk of decompensation and mortality. CONCLUSIONS Further evaluation of body composition abnormalities may help with development of targeted therapeutic strategies and improve outcome in patients with cirrhosis. Moreover, recognition of these abnormalities could improve prioritisation for liver transplantation as our current method based solely on liver function might lead to risk misclassification.
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Affiliation(s)
- Maryam Ebadi
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, AB, Canada
| | - Rahima A Bhanji
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, AB, Canada
| | - Puneeta Tandon
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, AB, Canada
| | - Vera Mazurak
- Division of Human Nutrition, University of Alberta, Edmonton, AB, Canada
| | - Vickie E Baracos
- Department of Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Aldo J Montano-Loza
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, AB, Canada
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Kimura N, Tsuchiya A, Oda C, Kimura A, Hosaka K, Tominaga K, Hayashi K, Yokoyama J, Terai S. Visceral Adipose Tissue Index and Hepatocellular Carcinoma Are Independent Predictors of Outcome in Patients with Cirrhosis Having Endoscopic Treatment for Esophageal Varices. Dig Dis 2020; 39:58-65. [PMID: 32450556 DOI: 10.1159/000508867] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 05/19/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The relationship between the amount of adipose tissue and advanced-stage liver cirrhosis with esophageal varices (EV) is unknown. We aimed to reveal the prognostic significance of adipose tissues in patients with liver cirrhosis. METHODS We enrolled 87 patients with EV who received initial endoscopic treatment and underwent scheduled treatments in our hospital. Computed tomography (CT) images were obtained of a 5-mm slice at the umbilical level. We evaluated the effect of mortality based on the visceral adipose tissue index (VATI), subcutaneous adipose tissue index (SATI), and visceral to subcutaneous adipose tissue ratio (VSR). RESULTS Cox hazard multivariate analysis showed that the presence of hepatocellular carcinoma (HCC; hazard ratio [HR]: 4.650, 95% confidence interval [CI]: 1.750-12.353, p = 0.002), γ-GTP (HR: 1.003, 95% CI: 1.001-1.006, p = 0.026), and VATI (HR: 1.057, 95% CI: 1.030-1.085, p < 0.001) significantly affected mortality. Cox hazard multivariate analysis for liver-related death was also significantly affected by HCC (HR: 1.057, 95% CI: 1.030-1.085, p < 0.001) and VATI (HR: 1.052, 95% CI: 1.019-1.086, p = 0.002). The difference between the Child-Pugh scores 12 months after treatment and that during initial treatment were significantly positively correlated with VATI (r = 0.326, p = 0.027). Patients with high VATI had a significantly higher frequency of HCC after EV treatment by Kaplan-Meier analysis (p = 0.044). CONCLUSION Our findings suggest that VATI measured by CT could significantly predict mortality in cirrhosis patients through decreasing liver function and increasing HCC frequency, and appropriately controlling VATI could improve their prognosis.
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Affiliation(s)
- Naruhiro Kimura
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan,
| | - Atsunori Tsuchiya
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Chiyumi Oda
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Atsushi Kimura
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Kazunori Hosaka
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Kentaro Tominaga
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Kazunao Hayashi
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Junji Yokoyama
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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The association between metabolic syndrome and Hepatitis C virus infection in the United States. Cancer Causes Control 2020; 31:569-581. [PMID: 32300943 DOI: 10.1007/s10552-020-01300-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 04/07/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Hepatitis C virus (HCV) infection is the prevalent risk factor for chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC) worldwide. The association between metabolic syndrome (MetS) and HCV infection has not been studied effectively, particularly among different ethnic/racial groups in the US. METHODS A retrospective cross-sectional study was conducted using data from the National Health and Nutrition Examination Survey (1999-2014). Unadjusted and adjusted associations were summarized using the prevalence ratio (PR) and 95% confidence interval (CI) after exploring possible interactions. RESULTS In the overall population, MetS was significantly associated with HCV infection with an interaction of age. After adjusting for all potential confounders, MetS was found to be significantly associated with HCV among non-obese and younger adults of age less than 60 years (PR 1.67, 95% CI 1.21-2.30, p = 0.002). MetS was also associated with an increased prevalence of HCV in each racial/ethnic group, while the association was strongly modified by age and obesity status of the subjects in different ethnic/racial groups. CONCLUSIONS MetS or its components are associated with an increased prevalence of HCV in some sub-populations of all ethnic/racial groups in the US. A better understanding of the pathophysiology of MetS associated with HCV is important as MetS may have a role in HCV infection treatment outcomes.
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Noh J. Sarcopenia as a Novel Risk Factor for Nonalcoholic Fatty Liver Disease. J Obes Metab Syndr 2020; 29:1-3. [PMID: 32182638 PMCID: PMC7118008 DOI: 10.7570/jomes20017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/08/2020] [Accepted: 03/11/2020] [Indexed: 12/22/2022] Open
Affiliation(s)
- Junghyun Noh
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
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Giorgi-Pierfranceschi M, López-Núñez JJ, Monreal M, Cattabiani C, Lodigiani C, Di Micco P, Bikdeli B, Braester A, Soler S, Dentali F. Morbid Obesity and Mortality in Patients With VTE: Findings From Real-Life Clinical Practice. Chest 2020; 157:1617-1625. [PMID: 32004553 DOI: 10.1016/j.chest.2019.12.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 12/03/2019] [Accepted: 12/14/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The influence of morbid obesity on mortality in patients receiving anticoagulant therapy for VTE has not been consistently evaluated. METHODS Data from the RIETE (Registro Informatizado Enfermedad TromboEmbólica) registry were used to compare the mortality risk during anticoagulation in patients with VTE and morbid obesity (BMI ≥ 40 kg/m2) vs those with normal weight (BMI, 18.5-24.9 kg/m2). Patients with or without active cancer were analyzed separately. RESULTS By September 2018, there were 1,642 patients with VTE and morbid obesity and 14,848 with normal weight in RIETE. Of these, 245 (5.5%) and 1,397 (11.6%), respectively, had cancer. Median duration of anticoagulant therapy was longer in the morbidly obese patients, with cancer (185 vs 114 days) or without cancer (203 vs 177 days). Among cancer patients, 44 (18.0%) morbidly obese and 1,377 (32.8%) patients with normal weight died during anticoagulation. Among those without cancer, 44 (3.1%) morbidly obese died and 601 (5.6%) with normal weight died. On bivariate analysis, morbid obesity was associated with a lower mortality rate, both in patients with cancer (hazard ratio, 0.34; 95% CI, 0.25-0.45) and in those without cancer (hazard ratio, 0.43; 95% CI, 0.32-0.58). Multivariable analysis confirmed a lower hazard of death in morbidly obese patients with cancer (hazard ratio, 0.68; 95% CI, 0.50-0.94) and without cancer (hazard ratio, 0.67; 95% CI, 0.49-0.96). The risk for VTE recurrences or major bleeding did not differ in patients with or without morbid obesity. CONCLUSIONS In patients with VTE, the risk for death during anticoagulation was about one-third lower in morbidly obese patients than in those with normal weight, independently of the presence of cancer.
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Affiliation(s)
| | - Juan J López-Núñez
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Universidad Autónoma de Barcelona, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Universidad Autónoma de Barcelona, Spain
| | - Chiara Cattabiani
- Department of Internal Medicine, Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Corrado Lodigiani
- Thrombosis and Hemorrhagic Diseases Center, Humanitas Clinical and Research Center - IRCCS, Rozzano (Mi), Italy
| | - Pierpaolo Di Micco
- Department of Internal Medicine and Emergency Room, Ospedale Buon Consiglio Fatebenefratelli, Naples, Italy
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, NY; Yale New Haven Health, Center for Outcomes Research & Evaluation, New Haven, CT; Cardiovascular Research Foundation, New York, NY
| | - Andrei Braester
- Department of Haematology, Azrieli School of Medicine in Galilee, Bar-ilan University, Safed, Israel
| | - Silvia Soler
- Department of Internal Medicine, Hospital Olot i Comarcal de la Garrotxa, Gerona, Spain
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38
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Hanai T, Shiraki M, Imai K, Suetsugu A, Takai K, Moriwaki H, Shimizu M. Reduced handgrip strength is predictive of poor survival among patients with liver cirrhosis: A sex-stratified analysis. Hepatol Res 2019; 49:1414-1426. [PMID: 31408558 DOI: 10.1111/hepr.13420] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 07/20/2019] [Accepted: 08/05/2019] [Indexed: 12/13/2022]
Abstract
AIM Handgrip strength (HGS) is a marker of sarcopenia and has been used to stratify an individual's risk of death. We aimed to assess the prognostic significance of HGS in patients with liver cirrhosis. METHODS In this retrospective study, we collated data of 563 consecutive patients admitted to our hospital with cirrhosis (375 men). A dynamometer was used to measure HGS. Body composition (including skeletal muscle and adipose tissue volumes) was estimated using computed tomography. Predictors of mortality were identified using sex-stratified multivariate analyses. RESULTS After adjustments for age, cirrhosis etiology, Child-Pugh score, and other confounding variables, HGS, but not body composition, was independently associated with mortality in male patients (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.94-0.99; P < 0.01) and female patients (HR, 0.91; 95% CI, 0.84-0.99; P = 0.02). Men with low HGS (<30 kg) had a higher risk of mortality (HR, 2.09; 95% CI, 1.39-3.17; P < 0.001), as did women with low (<15 kg) HGS (HR, 2.14; 95% CI, 1.16-4.01; P = 0.02). We could stratify the sex-specific risk of mortality in cirrhotic patients using HGS, regardless of coexistent hepatocellular carcinoma and the Child-Pugh class. CONCLUSIONS Reduced HGS, rather than skeletal muscle and adipose tissue volumes, is associated with an increased risk of mortality in patients of both sexes with liver cirrhosis. Measurement of HGS is a simple, cost-effective, and appropriate bedside assessment for the prediction of survival in patients with cirrhosis.
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Affiliation(s)
- Tatsunori Hanai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.,Division for Regional Cancer Control, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Makoto Shiraki
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kenji Imai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Atsushi Suetsugu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Koji Takai
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan.,Division for Regional Cancer Control, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hisataka Moriwaki
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
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39
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Lamarti E, Hickson M. The contribution of ascitic fluid to body weight in patients with liver cirrhosis, and its estimation using girth: a cross-sectional observational study. J Hum Nutr Diet 2019; 33:404-413. [PMID: 31775184 DOI: 10.1111/jhn.12721] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND There is a high prevalence of malnutrition among people with decompensated liver disease. Standard nutritional screening tools use weight and body mass index (BMI) to identify risk, although these are difficult to measure for those with ascites, often secondary to liver cirrhosis. Dietetic guidance suggests adjusting for ascitic weight by 2.2-14 kg, although there is a lack of evidence to substantiate these values. The present study aimed to measure the contribution of ascitic fluid weight and compare this with the current guidance, as well as to examine whether girth circumference can be used to estimate ascitic weight. METHODS A cross-sectional, observational study was conducted over 13 weeks. Participants attending for paracentesis were weighed, their girths measured, and BMI was calculated pre- and post-paracentesis. Fluid removed via paracentesis was recorded. Ethical approval was received (IRAS project ID: 218747). RESULTS Eighteen participants underwent paracentesis. The range of ascitic fluid drained was 3.8-19 L [mean (SD) = 8.7 (3.7) L]. Weight difference between pre- and post-paracentesis was in the range 4.5-20 kg [mean (SD) = 8.7 (3.9) kg]. Ascitic fluid weight is shown to be higher in each category (minimal, moderate, severe ascites) than the current guidance values. Weight difference was greater than 14 kg in 11% (n = 2) of participants. A strong, statistically significant relationship (rho = 0.68, P ≤ 0.01) between ascitic weight and pre-paracentesis girth was found. An equation was formulated to enable the estimation of ascitic fluid from pre-paracentesis girth. CONCLUSIONS Current dietetic guidance should be re-evaluated to reflect the greater weight differences identified. Measuring girth pre-paracentesis may help to inform dry weight estimation. Further research is required to verify the accuracy of estimating ascitic weight from pre-paracentesis girth.
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Affiliation(s)
- E Lamarti
- Therapy Department, Royal Cornwall Hospitals NHS Trust, Truro, UK.,Institute of Health and Community, University of Plymouth, Plymouth, UK
| | - M Hickson
- Institute of Health and Community, University of Plymouth, Plymouth, UK
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40
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Druml W, Zajic P, Winnicki W, Fellinger T, Metnitz B, Metnitz P. Association of Body Mass Index and Outcome in Acutely Ill Patients With Chronic Kidney Disease Requiring Intensive Care Therapy. J Ren Nutr 2019; 30:305-312. [PMID: 31732261 DOI: 10.1053/j.jrn.2019.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/23/2019] [Accepted: 09/14/2019] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE An association of body mass index (BMI) and outcome, the "obesity paradox," has been described in patients with chronic kidney disease (CKD) and end-stage renal disease. We sought to assess whether a potential beneficial effect of a high body mass is also seen in CKD patients with critical illness. METHODS In a retrospective analysis of a prospectively collected database of 123,416 patients from 107 Austrian intensive care units (ICUs) in whom BMI was available, the association of 6 groups of BMI and hospital mortality was assessed in 12,206 patients with CKD 3-5 by univariate and multivariate logistic regression analyses. RESULTS Patients with CKD were sicker, had a longer ICU stay, and had a higher ICU and hospital mortality than those without. The association of BMI and outcome in CKD patients indicated a U-shaped curve with the highest mortality in patients with BMI <20 and ≥40, and the lowest with a BMI between ≥25 and <40. This relationship was also significant in a multivariate analysis adjusted for severity of illness assessed by Simplified Acute Physiology Score III score, age, gender, admission diagnosis, and pre-existing comorbidities. It was not found in patients with CKD 5 on renal replacement therapy, in patients below 60 years of age, and those with diabetes mellitus requiring insulin treatment. CONCLUSIONS BMI is associated with better outcomes in CKD 3-5 patients who have acquired acute intermittent diseases and are admitted to an ICU, but not those requiring renal replacement therapy. This higher tolerance to acute disease processes may in part explain the "obesity paradox" observed in CKD patients.
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Affiliation(s)
- Wilfred Druml
- Division of Nephrology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Paul Zajic
- Division of General Anaesthesiology, Emergency and Intensive Care Medicine, Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria.
| | - Wolfgang Winnicki
- Division of Nephrology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Tobias Fellinger
- Austrian Center for Documentation and Quality Assurance in Intensive Care (ASDI), Vienna, Austria
| | - Barbara Metnitz
- Austrian Center for Documentation and Quality Assurance in Intensive Care (ASDI), Vienna, Austria
| | - Philipp Metnitz
- Division of General Anaesthesiology, Emergency and Intensive Care Medicine, Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
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41
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Obesity in the Liver Transplant Setting. Nutrients 2019; 11:nu11112552. [PMID: 31652761 PMCID: PMC6893648 DOI: 10.3390/nu11112552] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/23/2019] [Accepted: 09/25/2019] [Indexed: 12/12/2022] Open
Abstract
The obesity epidemic has resulted in an increased prevalence of obesity in liver transplant (LT) candidates and in non-alcoholic fatty liver disease (NAFLD) becoming the fastest growing indication for LT. LT teams will be dealing with obesity in the coming years, and it is necessary for them to recognize some key aspects surrounding the LT in obese patients. Obesity by itself should not be considered a contraindication for LT, but it should make LT teams pay special attention to cardiovascular risk assessment, in order to properly select candidates for LT. Obese patients may be at increased risk of perioperative respiratory and infectious complications, and it is necessary to establish preventive strategies. Data on patient and graft survival after LT are controversial and scarce, especially for long-term outcomes, but morbid obesity may adversely affect these outcomes, particularly in NAFLD. The backbone of obesity treatment should be diet and exercise, whilst being careful not to precipitate or worsen frailty and sarcopenia. Bariatric surgery is an alternative for treatment of obesity, and the ideal timing regarding LT is still unknown. Sleeve gastrectomy is probably the procedure that has the best evidence in LT because it offers a good balance between safety and efficacy.
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42
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Curcic IB, Berkovic MC, Kuna L, Roguljic H, Smolic R, Varzic SC, Jukic LV, Smolic M. Obesity Paradox in Chronic Liver Diseases: Product of Bias or a Real Thing? J Clin Transl Hepatol 2019; 7:275-279. [PMID: 31608220 PMCID: PMC6783679 DOI: 10.14218/jcth.2019.00029] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/08/2019] [Accepted: 09/09/2019] [Indexed: 12/18/2022] Open
Abstract
In recent years, evidence supporting the theory of obesity paradox has increased, showing that obese/overweight people with prevalent chronic diseases experience lower mortality compared with patients of normal weight. So far, evidence is most comprehensive in cardiovascular and chronic renal diseases; however, published studies are prone to many biases, enabling us to reach a definite conclusion. Available data in chronic liver disease is scarce and ambiguous. Obesity is traditionally associated with nonalcoholic fatty liver disease and steatosis in viral hepatitis and as such one would not expect the obesity paradox to be a real possibility in liver disease. Yet, there seem to be new data indicating the opposite - the obesity paradox exists in severe and end-stage liver cirrhosis, which could be attributed to a better lean mass in patients with higher body mass index, meaning that sarcopenia, as one of the most important prognostic factors of survival, is less likely to be present. Nonetheless, the problem of various methodological problems addressing the association between body weight and mortality, which is present both in liver disease and other chronic diseases, are preventing us from attaining an unanimous conclusion. Still, we should be aware that the obesity paradox might be true, especially in severe and end-stage illness. This suggests focusing our efforts toward preserving or building up fat-free mass and decreasing inflammatory activity responsible for catabolism and sarcopenia, and implying that the underlaying cause should be treated.
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Affiliation(s)
- Ines Bilic Curcic
- Department of Pharmacology, Faculty of Medicine, J. J. Strossmayer University of Osijek, Osijek, Croatia
- Department of Diabetes, Endocrinology and Metabolism Disorders, Osijek University Hospital Centre, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Maja Cigrovski Berkovic
- Department for Endocrinology, Diabetes and Metabolism University Hospital Center, “Sestre Milosrdnice”, Zagreb, Croatia
| | - Lucija Kuna
- Department of Pharmacology and Biochemistry, Faculty of Dental Medicine and Health, J. J. Strossmayer University of Osijek, Osijek, Croatia
| | - Hrvoje Roguljic
- Department of Pharmacology, Faculty of Medicine, J. J. Strossmayer University of Osijek, Osijek, Croatia
- Department for Cardiovascular Disease, Osijek University Hospital, Osijek, Croatia
| | - Robert Smolic
- Department of Gastroenterology and Hepatology, Osijek University Hospital Centre, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
- Department of Pathophysiology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Silvija Canecki Varzic
- Department of Diabetes, Endocrinology and Metabolism Disorders, Osijek University Hospital Centre, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
- Department of Internal Medicine, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Lucija Virovic Jukic
- Department of Gastroenterology and Hepatology, Sisters of Mercy University Hospital, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Martina Smolic
- Department of Pharmacology, Faculty of Medicine, J. J. Strossmayer University of Osijek, Osijek, Croatia
- Department of Pharmacology and Biochemistry, Faculty of Dental Medicine and Health, J. J. Strossmayer University of Osijek, Osijek, Croatia
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43
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Shrestha MP, Taleban S. Obesity Is Associated with Increased Risk of Colectomy in Inflammatory Bowel Disease Patients Hospitalized with Clostridium difficile Infection. Dig Dis Sci 2019; 64:1632-1639. [PMID: 30569334 DOI: 10.1007/s10620-018-5423-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 12/07/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Obesity and inflammatory bowel disease (IBD) are associated with increased risk of Clostridium difficile infection (CDI). The effect of obesity on IBD course and development of complications is poorly understood. We performed this study to examine the effect of obesity on CDI-related morbidity and mortality in hospitalized patients with IBD. METHODS We used data from the National Inpatient Sample across five study years (2010-2014) to identify patients ≥ 18 years hospitalized with both CDI and IBD. We compared the outcomes of in-hospital mortality, partial or total colectomy, hospital length of stay, and hospital charges between obese and non-obese IBD-CDI patients. Analysis included univariate and multivariate linear and logistic regression analyses. RESULTS Of 304,298 hospitalized patients with IBD, 13,517 (4.4%) patients had CDI. Of these, 996 (7.4%) patients were obese. Obese IBD-CDI patients had a higher risk of colectomy (adjusted odds ratio, AOR 1.60, 95% CI 1.30-1.96; p < 0.001), longer hospital length of stay (difference 0.8 days, 95% CI 0.02-1.58; p = 0.04), and higher hospital charges (difference $11,051, 95% CI 1939-20,163; p = 0.02) than non-obese IBD-CDI patients, but no significant difference in mortality was found between the two groups. CONCLUSIONS Obesity is associated with a 60% increase in the risk of colectomy, longer hospital stay, and higher charges in IBD patients hospitalized with CDI. Further epidemiological and clinical studies are needed to confirm these findings.
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Affiliation(s)
- Manish P Shrestha
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Sasha Taleban
- Division of Gastroenterology, University of Arizona College of Medicine, 1501 N Campbell Ave, PO Box 24502B, Tucson, AZ, 85724, USA. .,Department of Medicine, Arizona Center of Aging, Tucson, AZ, USA.
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44
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Persaud SR, Lieber AC, Donath E, Stingone JA, Dangayach NS, Zhang X, Mocco J, Kellner CP. Obesity Paradox in Intracerebral Hemorrhage. Stroke 2019; 50:999-1002. [DOI: 10.1161/strokeaha.119.024638] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background and Purpose—
Although obesity is an established risk factor for cardiovascular disease and stroke, studies have shown evidence of an obesity paradox—a protective effect of obesity in patients who already have these disease states. Data on the obesity paradox in intracerebral hemorrhage is limited.
Methods—
Clinical data for adult intracerebral hemorrhage patients were extracted from the National Inpatient Sample between 2007 and 2014. Multivariable logistic regression analyzed the association of body habitus with in-hospital mortality, discharge disposition, length of stay, tracheostomy or gastrostomy placement, and ventriculoperitoneal shunt placement.
Results—
There were 99 212 patients who were eligible. Patients with both obesity (OR=0.69; 95% CI=0.62–0.76;
P
<0.001) and morbid obesity (OR=0.85; 95% CI=0.74–0.97;
P
=0.02) were associated with decreased odds of in-hospital mortality. Morbid obesity was significantly associated with increased odds of a tracheostomy or gastrostomy placement (OR=1.42; 1.20–1.69;
P
<0.001) and decreased odds of a routine discharge disposition (OR=0.84; 0.74–0.97;
P
=0.014).
Conclusions—
Obesity and morbid obesity appear to protect against mortality in intracerebral hemorrhage.
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Affiliation(s)
- Steven R. Persaud
- From the Department of Neurosurgery (S.R.P., A.C.L., N.S.D., X.Z., J.M., C.P.K.), Mount Sinai Hospital, New York
| | - Adam C. Lieber
- From the Department of Neurosurgery (S.R.P., A.C.L., N.S.D., X.Z., J.M., C.P.K.), Mount Sinai Hospital, New York
| | - Elie Donath
- Department of Medicine, Division of General Internal Medicine (E.D.), Mount Sinai Hospital, New York
| | - Jeanette A. Stingone
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York (J.A.S.)
| | - Neha S. Dangayach
- From the Department of Neurosurgery (S.R.P., A.C.L., N.S.D., X.Z., J.M., C.P.K.), Mount Sinai Hospital, New York
| | - Xiangnan Zhang
- From the Department of Neurosurgery (S.R.P., A.C.L., N.S.D., X.Z., J.M., C.P.K.), Mount Sinai Hospital, New York
| | - J Mocco
- From the Department of Neurosurgery (S.R.P., A.C.L., N.S.D., X.Z., J.M., C.P.K.), Mount Sinai Hospital, New York
| | - Christopher P. Kellner
- From the Department of Neurosurgery (S.R.P., A.C.L., N.S.D., X.Z., J.M., C.P.K.), Mount Sinai Hospital, New York
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45
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Eslamparast T, Montano-Loza AJ, Raman M, Tandon P. Sarcopenic obesity in cirrhosis-The confluence of 2 prognostic titans. Liver Int 2018; 38:1706-1717. [PMID: 29738109 DOI: 10.1111/liv.13876] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 04/17/2018] [Indexed: 02/13/2023]
Abstract
Sarcopenia and obesity are 2 major health conditions with a growing prevalence in cirrhosis. The concordance of these 2 conditions, sarcopenic obesity, is associated with higher rates of mortality and impact on the metabolic profile and physical function than either condition alone. To date, there is little consensus surrounding the diagnostic criteria for sarcopenia, obesity or as a result, sarcopenic obesity in patients with cirrhosis. Cross-sectional imaging, although the most accurate diagnostic technique, has practical limitations for routine use in clinical practice. Management strategies are focused on increasing muscle mass and strength. The present review provides an overview of the diagnosis, pathophysiology, prognostic implications and management strategies available for sarcopenic obesity in cirrhosis. We also discuss the associated condition myosteatosis, the pathological accumulation of fat in skeletal muscle. Much work needs to be done to advance both clinical care and research in this area. Future directions require consensus definitions for sarcopenia, obesity and sarcopenic obesity, an expansion of our understanding of the complex pathogenesis of the muscle-liver-adipose tissue axis in cirrhosis and evidence to support management recommendations for nutrition, exercise and pharmacological therapies.
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Affiliation(s)
| | | | - Maitreyi Raman
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
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46
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Ebadi M, Tandon P, Moctezuma-Velazquez C, Ghosh S, Baracos VE, Mazurak VC, Montano-Loza AJ. Low subcutaneous adiposity associates with higher mortality in female patients with cirrhosis. J Hepatol 2018; 69:608-616. [PMID: 29709682 DOI: 10.1016/j.jhep.2018.04.015] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 04/03/2018] [Accepted: 04/18/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Two major body compartments, skeletal muscle and adipose tissue, exhibit independent functions. We aimed to explore the prognostic significance of skeletal muscle, visceral and subcutaneous adipose tissue, according to sex, in patients with cirrhosis assessed for liver transplantation (LT). METHODS CT images taken at the 3rd lumbar vertebra from 677 patients were quantified for three body composition indexes (cm2/m2), visceral adipose tissue index, subcutaneous adipose tissue index (SATI), and skeletal muscle index (SMI). Cox proportional and competing-risk analysis hazard models were conducted to assess associations between mortality and body composition. RESULTS The majority of patients were male (67%) with a mean age of 57 ± 7 years, model for end-stage liver disease (MELD) score of 14 ± 8 and mean body mass index of 27 ± 6 kg/m2. Despite similar body mass index between the sexes, male patients had greater SMI (53 ± 12 vs. 45 ± 9 cm2/m2), whereas SATI (67 ± 52 vs. 48 ± 37 cm2/m2) was higher in females (p <0.001 for each). In sex stratified multivariate analyses after adjustment for MELD score and other confounding variables, SATI in females (hazard ratio [HR] 0.99; 95% CI 0.98-1.00; p = 0.01) and SMI in males (HR 0.98; 95% CI 0.96-1.00; p = 0.02) were significant predictors of mortality. Female patients with low SATI (<60 cm2/m2) had a higher risk of mortality (HR 2.06; 95% CI 1.08-3.91; p = 0.03). Using competitive risk analysis in female patients listed for LT, low SATI was also an independent predictor of mortality (subdistribution HR 2.80; 95% CI 1.28-6.12; p = 0.01) after adjusting for MELD, and other confounding factors. CONCLUSIONS A lower SATI is associated with higher mortality in female patients with cirrhosis. Subcutaneous adipose tissue has a favorable metabolic profile - low SATI may reflect depletion of this major energy reservoir, leading to poor clinical outcomes. LAY SUMMARY We looked at the importance of two of the main body compartments, skeletal muscle and adipose tissue (fat) on the prognosis of males and females with end-stage liver disease. Lower amounts of subcutaneous fat but not visceral fat (around internal organs), are associated with higher mortality in female patients with end-stage liver disease. However, low skeletal muscle predicts mortality in male patients with end-stage liver disease.
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Affiliation(s)
- Maryam Ebadi
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Puneeta Tandon
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, Alberta, Canada
| | | | - Sunita Ghosh
- Department of Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Vickie E Baracos
- Department of Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Vera C Mazurak
- Division of Human Nutrition, University of Alberta, Edmonton, Alberta, Canada
| | - Aldo J Montano-Loza
- Division of Gastroenterology & Liver Unit, University of Alberta Hospital, Edmonton, Alberta, Canada.
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47
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Xia JY, Lloyd-Jones DM, Khan SS. Association of body mass index with mortality in cardiovascular disease: New insights into the obesity paradox from multiple perspectives. Trends Cardiovasc Med 2018; 29:220-225. [PMID: 30172579 DOI: 10.1016/j.tcm.2018.08.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/07/2018] [Accepted: 08/14/2018] [Indexed: 12/16/2022]
Abstract
Over the past 4 decades, prevalence of obesity has increased rapidly at both the national and global level and presents a major public health challenge. Obesity is associated with increased risk of morbidity from cardiovascular diseases. Data suggesting that the presence of obesity may be protective in individuals with clinically manifest cardiovascular disease have led to discussion of an "obesity paradox", stirring controversy and leading to unclear messaging regarding the true health risks of excess weight. This review explores the relationship between obesity and fatal and non-fatal outcomes in patients with prevalent cardiovascular disease and offers novel insights into the obesity paradox.
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Affiliation(s)
- Jonathan Y Xia
- Department of Medicine, Northwestern University Feinberg School of Medicine, United States
| | - Donald M Lloyd-Jones
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, United States
| | - Sadiya S Khan
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 680N. Lake Shore Drive, 14-002, Chicago, IL 60611, United States; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, United States.
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48
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Schiavo L, Busetto L, Cesaretti M, Zelber-Sagi S, Deutsch L, Iannelli A. Nutritional issues in patients with obesity and cirrhosis. World J Gastroenterol 2018; 24:3330-3346. [PMID: 30122874 PMCID: PMC6092576 DOI: 10.3748/wjg.v24.i30.3330] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/15/2018] [Accepted: 06/25/2018] [Indexed: 02/06/2023] Open
Abstract
Obesity and metabolic syndrome are considered as responsible for a condition known as the non-alcoholic fatty liver disease that goes from simple accumulation of triglycerides to hepatic inflammation and may progress to cirrhosis. Patients with obesity also have an increased risk of primary liver malignancies and increased body mass index is a predictor of decompensation of liver cirrhosis. Sarcopenic obesity confers a risk of physical impairment and disability that is significantly higher than the risk induced by each of the two conditions alone as it has been shown to be an independent risk factor for chronic liver disease in patients with obesity and a prognostic negative marker for the evolution of liver cirrhosis and the results of liver transplantation. Cirrhotic patients with obesity are at high risk for depletion of various fat-soluble, water-soluble vitamins and trace elements and should be supplemented appropriately. Diet, physical activity and protein intake should be carefully monitored in these fragile patients according to recent recommendations. Bariatric surgery is sporadically used in patients with morbid obesity and cirrhosis also in the setting of liver transplantation. The risk of sarcopenia, micronutrient status, and the recommended supplementation in patients with obesity and cirrhosis are discussed in this review. Furthermore, the indications and contraindications of bariatric surgery-induced weight loss in the cirrhotic patient with obesity are discussed.
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Affiliation(s)
- Luigi Schiavo
- Department of Translational Medical Science, University of Campania “Luigi Vanvitelli”, Naples 80131, Italy
- IX Division of General Surgery, Vascular Surgery and Applied Biotechnology, Naples University Policlinic, Naples 80131, Italy
| | - Luca Busetto
- Department of Medicine, University of Padua, Padua 35128, Italy
- Center for the Study and the Integrated Management of Obesity, University Hospital of Padua, Padua 35128, Italy
| | - Manuela Cesaretti
- Department of HPB Surgery and Liver Transplantation, Hôpital Beaujon, AP-HP, Clichy 92110, France
- Department of Nanophysics, Italian Institute of Technology, Genova 16163, Italy
| | - Shira Zelber-Sagi
- School of Public Health, University of Haifa, Haifa 3498838, Israel
- Department of Gastroenterology and Liver disease, Tel Aviv Medical Center, 62431, Tel-Aviv 62431, Israel
| | - Liat Deutsch
- Department of Gastroenterology and Liver disease, Tel Aviv Medical Center, 62431, Tel-Aviv 62431, Israel
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 62431, Israel
| | - Antonio Iannelli
- Digestive Unit, Archet 2 Hospital, University Hospital of Nice, F-06202, Nice, France; Inserm, U1065, Team 8 “Hepatic complications of obesity”, Nice F-06204, France
- University of Nice Sophia-Antipolis, Nice F-06107, France
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Kok B, Karvellas CJ, Abraldes JG, Jalan R, Sundaram V, Gurka D, Keenan S, Kumar A, Martinka G, Bookatz B, Wood G, Kumar A. The impact of obesity in cirrhotic patients with septic shock: A retrospective cohort study. Liver Int 2018; 38:1230-1241. [PMID: 29194916 DOI: 10.1111/liv.13648] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 11/17/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS The prevalence of obesity in cirrhosis is rising. The impact of obesity in critically ill cirrhotic patients with sepsis/septic shock has not been evaluated. This study aimed to examine the relationship between obesity and mortality in cirrhotic patients admitted to the intensive care unit with septic shock. METHODS A retrospective cohort study of all cirrhotic patients with septic shock (n = 362) and a recorded body mass index (BMI) from an international, multicentre (CATSS) database (1996-2015) was performed. Patients were classified by BMI as per WHO categories. Primary outcome was in-hospital mortality. Multivariate logistic regression analyses were carried out to determine independent associations with outcome. RESULTS In this analysis, mean age was 56.4 years, and 62% were male. Median BMI was 26.3%, and 57.7% were overweight/obese. In-hospital mortality was 71%. Obese patients were more likely to have comorbidities of cardiac disease, lung disease and diabetes. Compared to survivors (n = 105), non-survivors (n = 257) had significantly higher MELD and APACHEII scores and higher requirements for renal replacement therapy and mechanical ventilation (P < .03 for all). Using multivariable logistic regression, increase in BMI (OR 1.07, P = .034), time delay to appropriate antimicrobials (OR 1.16 per hour, P = .003), APACHEII (OR 1.12 per unit, P = .008) and peak lactate (OR 1.15, P = .028) were independently associated with in-hospital mortality. CONCLUSIONS Septic shock in cirrhosis carries a high mortality. Increased BMI is common in critically ill cirrhotic patients and independently associated with increased in-hospital mortality.
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Affiliation(s)
- Beverley Kok
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada.,Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Constantine J Karvellas
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada.,Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Juan G Abraldes
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Rajiv Jalan
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Vinay Sundaram
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David Gurka
- Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL, USA
| | - Sean Keenan
- Royal Columbian Hospital, New Westminster, BC, Canada
| | - Aseem Kumar
- Laurentian University, Sudbury, Ontario, Canada
| | - Greg Martinka
- Richmond General Hospital, Richmond, British Columbia, Canada
| | | | - Gordon Wood
- Victoria General Hospital, Victoria, British Columbia, Canada
| | - Anand Kumar
- Section of Critical Care Medicine and Section of Infectious Disease, Health Sciences Center and St. Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
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50
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Body mass index as a biomarker for the evaluation of the "Obesity Paradox" among inpatients. Clin Nutr 2017; 38:412-421. [PMID: 29291899 DOI: 10.1016/j.clnu.2017.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 11/19/2017] [Accepted: 12/03/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Overweight and obesity are, on the one hand, recognized as risk factors for many health-related disorders, and, on the other, as favorable prognostic factors in various patients treated for several different conditions; what is called the "obesity paradox". Until now, the existence of this phenomenon among a general population of consecutive inpatients has not been evaluated. We decided, therefore, to perform an evaluation. PATIENTS AND METHODS Historical prospective analysis of the medical documentation of 23 603 hospitalizations during two consecutive years in one center was performed. The outcomes measured were as follows: length of stay, in-hospital all-cause mortality, and non-scheduled readmission in the 14-day, 30-day and one-year periods following discharge. RESULTS Overweight and obese patients had a lower or similar prevalence of the measured outcomes than malnourished patients and those of normal weight. Adjustment of the standard WHO BMI ranges for patients aged ≥65 y (normal weight BMI range 23-33 kg/m2) made these differences more apparent. In logistic regression, the ratio of fat to fat-free body mass was a stronger and unfavorable risk factor compared with BMI for the measured outcomes. CONCLUSIONS The greatest risk of all-cause in-hospital death and readmission concerned malnourished inpatients. Compared to patients with a normal BMI range, overweight and obesity had a lower or similar (but not greater) risk of the outcomes measured. However, due to several BMI limitations, our observations should be interpreted as suggesting a "BMI paradox", rather than an "obesity paradox".
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