Malnutrition and sarcopenia predict post-liver transplantation outcomes independently of the Model for End-stage Liver Disease score

Maria Kalafateli, Konstantinos Mantzoukis, Yan Choi Yau, Ali O Mohammad, Simran Arora, Susana Rodrigues, Marie de Vos, Kassiani Papadimitriou, Douglas Thorburn, James O'Beirne, David Patch, Massimo Pinzani, Marsha Y Morgan, Banwari Agarwal, Dominic Yu, Andrew K Burroughs, Emmanuel A Tsochatzis, Maria Kalafateli, Konstantinos Mantzoukis, Yan Choi Yau, Ali O Mohammad, Simran Arora, Susana Rodrigues, Marie de Vos, Kassiani Papadimitriou, Douglas Thorburn, James O'Beirne, David Patch, Massimo Pinzani, Marsha Y Morgan, Banwari Agarwal, Dominic Yu, Andrew K Burroughs, Emmanuel A Tsochatzis

Abstract

Background: Although malnutrition and sarcopenia are prevalent in cirrhosis, their impact on outcomes following liver transplantation is not well documented.

Methods: The associations of nutritional status and sarcopenia with post-transplant infections, requirement for mechanical ventilation, intensive care (ICU) and hospital stay, and 1 year mortality were assessed in 232 consecutive transplant recipients. Nutritional status and sarcopenia were assessed using the Royal Free Hospital-Global Assessment (RFH-GA) tool and the L3-psoas muscle index (L3-PMI) on CT, respectively.

Results: A wide range of RFH-SGA and L3-PMI were observed within similar Model for End-stage Liver Disease (MELD) sub-categories. Malnutrition and sarcopenia were independent predictors of all outcomes. Post-transplant infections were associated with MELD (OR = 1.055, 95%CI = 1.002-1.11) and severe malnutrition (OR = 6.55, 95%CI = 1.99-21.5); ventilation > 24 h with MELD (OR = 1.1, 95%CI = 1.036-1.168), severe malnutrition (OR = 8.5, 95%CI = 1.48-48.87) and suboptimal donor liver (OR = 2.326, 95%CI = 1.056-5.12); ICU stay > 5 days, with age (OR = 1.054, 95%CI = 1.004-1.106), MELD (OR = 1.137, 95%CI = 1.057-1.223) and severe malnutrition (OR = 7.46, 95%CI = 1.57-35.43); hospital stay > 20 days with male sex (OR = 2.107, 95%CI = 1.004-4.419) and L3-PMI (OR = 0.996, 95%CI = 0.994-0.999); 1 year mortality with L3-PMI (OR = 0.996, 95%CI = 0.992-0.999). Patients at the lowest L3-PMI receiving suboptimal grafts had longer ICU/hospital stay and higher incidence of infections.

Conclusions: Malnutrition and sarcopenia are associated with early post-liver transplant morbidity/mortality. Allocation indices do not include nutritional status and may jeopardize outcomes in nutritionally compromised individuals.

Keywords: Cirrhosis; Morbidity; Mortality; Nutritional assessment; Prognosis.

Figures

Figure 1
Figure 1
Box plots of L3‐psoas muscle index (L3‐PMI) for male and female patients stratified according to Royal Free Hospital‐Global Assessment (RFH‐GA). Males well‐nourished: median PMI = 492.7 (range 224.2–856.1), mild/moderately malnourished: median PMI = 399.05.4 (187.3–648.7), severely malnourished: median PMI = 313.5 (195.8–454.9). Females well‐nourished: median PMI = 388.8 (range 210.4–763.8), mild/moderately malnourished: median PMI = 309.4 (78.9–589.9), severely malnourished: median PMI = 317.65 (215.8–508.1).
Figure 2
Figure 2
Box‐plots of L3‐psoas muscle index (L3‐PMI) for male and female patients stratified according to Model for End‐stage Liver Disease (MELD). Males: median L3‐PMI levels were 486.6 (range 200.8–856.1), 417.6 (178.9–817.3), 415.15 (236.7–806.2), 335.6 (187.3–536.2), and 483.2 (162.5–983) mm2/m2 for MELD score ≤10, 11–15, 16–20, 21–25, and >25, respectively. Females: median L3‐PMI levels were 370.5 (range 78.9–554.6), 330.75 (135.4–589.9), 368.3 (150.5–763.8), 308 (205.4–392.3), and 359.9 (215.8–394.9) mm2/m2 for MELD score ≤10, 11–15, 16–20, 21–25, and >25, respectively.
Figure 3
Figure 3
Nutritional status of the transplant recipients assessed by Royal Free Hospital‐Global Assessment (RFH‐GA) stratified according to Model for End‐stage Liver Disease (MELD) score.

References

    1. Tsochatzis EA, Bosch J, Burroughs AK. Liver cirrhosis. Lancet 2014;383:1749–1761.
    1. Cabre E, Gassull MA. Nutrition in liver disease. Curr Opin Clin Nutr Metab Care 2005;8:545–551.
    1. Cheung K, Lee SS, Raman M. Prevalence and mechanisms of malnutrition in patients with advanced liver disease, and nutrition management strategies. Clin Gastroenterol Hepatol: the official clinical practice journal of the American Gastroenterological Association 2012;10:117–125.
    1. Muscaritoli M, Anker SD, Argiles J, Aversa Z, Bauer JM, Biolo G, et al Consensus definition of sarcopenia, cachexia and pre‐cachexia: joint document elaborated by Special Interest Groups (SIG) “cachexia–anorexia in chronic wasting diseases” and “nutrition in geriatrics”. Clin Nutr 2010;29:154–159.
    1. Carvalho L, Parise ER. Evaluation of nutritional status of nonhospitalized patients with liver cirrhosis. Arq Gastroenterol 2006;43:269–274.
    1. Sam J, Nguyen GC. Protein‐calorie malnutrition as a prognostic indicator of mortality among patients hospitalized with cirrhosis and portal hypertension. Liver Int: official journal of the International Association for the Study of the Liver 2009;29:1396–1402.
    1. Bernal W, Martin‐Mateos R, Lipcsey M, Tallis C, Woodsford K, McPhail MJ, et al Aerobic capacity during cardiopulmonary exercise testing and survival with and without liver transplantation for patients with chronic liver disease. Liver Transpl: official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society 2014;20:54–62.
    1. Johnson TM, Overgard EB, Cohen AE, DiBaise JK. Nutrition assessment and management in advanced liver disease. Nutr Clin Pract: official publication of the American Society for Parenteral and Enteral Nutrition 2013;28:15–29.
    1. Moctezuma‐Velazquez C, Garcia‐Juarez I, Soto‐Solis R, Hernandez‐Cortes J, Torre A. Nutritional assessment and treatment of patients with liver cirrhosis. Nutrition 2013;29:1279–1285.
    1. Montano‐Loza AJ. Muscle wasting: a nutritional criterion to prioritize patients for liver transplantation. Curr Opin Clin Nutr Metab Care 2014;17:219–225.
    1. Morgan MY, Madden AM, Soulsby CT, Morris RW. Derivation and validation of a new global method for assessing nutritional status in patients with cirrhosis. Hepatology 2006;44:823–835.
    1. Gunsar F, Raimondo ML, Jones S, Terreni N, Wong C, Patch D, et al Nutritional status and prognosis in cirrhotic patients. Aliment Pharmacol Ther 2006;24:563–572.
    1. Cruz RJ Jr, Dew MA, Myaskovsky L, Goodpaster B, Fox K, Fontes P, et al Objective radiologic assessment of body composition in patients with end‐stage liver disease: going beyond the BMI. Transplantation 2013;95:617–622.
    1. Prado CM, Lieffers JR, McCargar LJ, Reiman T, Sawyer MB, Martin L, et al Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population‐based study. Lancet Oncol 2008;9:629–635.
    1. Montano‐Loza AJ, Meza‐Junco J, Prado CM, Lieffers JR, Baracos VE, Bain VG, et al Muscle wasting is associated with mortality in patients with cirrhosis. Clin Gastroenterol Hepatol: the official clinical practice journal of the American Gastroenterological Association 2012;10:166–173, 73 e1.
    1. Durand F, Buyse S, Francoz C, Laouenan C, Bruno O, Belghiti J, et al Prognostic value of muscle atrophy in cirrhosis using psoas muscle thickness on computed tomography. J Hepatol 2014;60:1151–1157.
    1. Tandon P, Ney M, Irwin I, Ma MM, Gramlich L, Bain VG, et al Severe muscle depletion in patients on the liver transplant wait list: its prevalence and independent prognostic value. Liver Transpl: official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society 2012;18:1209–1216.
    1. Krell RW, Kaul DR, Martin AR, Englesbe MJ, Sonnenday CJ, Cai S, et al Association between sarcopenia and the risk of serious infection among adults undergoing liver transplantation. Liver Transpl: official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society 2013;19:1396–1402.
    1. Montano‐Loza AJ, Meza‐Junco J, Baracos VE, Prado CM, Ma M, Meeberg G, et al Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation. Liver Transpl: official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society 2014;20:640–648.
    1. Schaubel DE, Guidinger MK, Biggins SW, Kalbfleisch JD, Pomfret EA, Sharma P, et al Survival benefit‐based deceased‐donor liver allocation. Am J Transplant: official journal of the American Society of Transplantation and the American Society of Transplant Surgeons 2009;9:970–981.
    1. Neuberger J, Gimson A, Davies M, Akyol M, O'Grady J, Burroughs A, et al Selection of patients for liver transplantation and allocation of donated livers in the UK. Gut 2008;57:252–257.
    1. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988;16:128–140.
    1. Mendenhall CL. Protein‐calorie malnutrition in alcoholic liver disease In Watson RR, Watzl B, eds. Nutrition and Alcohol. Boca Raton, FL: CRC Press; 1992. p363–384.
    1. Englesbe MJ, Patel SP, He K, Lynch RJ, Schaubel DE, Harbaugh C, et al Sarcopenia and mortality after liver transplantation. J Am Coll Surg 2010;211:271–278.
    1. Pahor M, Manini T, Cesari M. Sarcopenia: clinical evaluation, biological markers and other evaluation tools. J Nutr Health Aging 2009;13:724–728.
    1. Visser M. Towards a definition of sarcopenia—results from epidemiologic studies. J Nutr Health Aging 2009;13:713–716.
    1. Rohrbach J, Stickel F, Schmid P, Thormann W, Kovari H, Scherrer A, et al Changes in biomarkers of liver disease during successful combination antiretroviral therapy in HIV‐HCV‐coinfected individuals. Antivir Ther 2014;19:149–159.
    1. Pugh RN, Murray‐Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973;60:646–649.
    1. Gonzalez FX, Rimola A, Grande L, Antolin M, Garcia‐Valdecasas JC, Fuster J, et al Predictive factors of early postoperative graft function in human liver transplantation. Hepatology 1994;20:565–573.
    1. Feng S, Goodrich NP, Bragg‐Gresham JL, Dykstra DM, Punch JD, DebRoy MA, et al Characteristics associated with liver graft failure: the concept of a donor risk index. Am J Transplant: official journal of the American Society of Transplantation and the American Society of Transplant Surgeons 2006;6:783–790.
    1. Heuman DM, Abou‐Assi SG, Habib A, Williams LM, Stravitz RT, Sanyal AJ, et al Persistent ascites and low serum sodium identify patients with cirrhosis and low MELD scores who are at high risk for early death. Hepatology 2004;40:802–810.
    1. Merli M, Giusto M, Gentili F, Novelli G, Ferretti G, Riggio O, et al Nutritional status: its influence on the outcome of patients undergoing liver transplantation. Liver Int: official journal of the International Association for the Study of the Liver 2010;30:208–214.
    1. Campillo B, Richardet JP, Scherman E, Bories PN. Evaluation of nutritional practice in hospitalized cirrhotic patients: results of a prospective study. Nutrition 2003;19:515–521.
    1. Tsochatzis EA, Bosch J, Burroughs AK. New therapeutic paradigm for patients with cirrhosis. Hepatology 2012;56:1983–1992.

Source: PubMed

Patrocinadores e Colaboradores

Condições médicas

Intervenções de drogas

3
Se inscrever