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Sarcopenia: Prognostic Impact on Cirrhosis
( Sang Gyune Kim ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1
Sarcopenia is a new clinical entity related to muscle decline, which has attracted a great deal of attention among clinicians because of its detrimental effect on clinical outcomes. Relevant pathways may vary depending on the underlying disease, but muscle depletion occurs due to imbalances in muscle formation and breakdown. According to recent meta-analysis, sarcopenia in patients with liver cirrhosis is an important prognostic factor, independent of MELD and CTP scores (Figure 1).1 In this study, the prevalence rate of sarcopenia among all cirrhotic patients was about 48%, and 2-fold more among men with a rate of 62% compared to that of 36% for women. Interestingly, Asians had a HR 2.45 (95% confidence interval (CI) = 1.44 ± 4.16, P = 0.001) of mortality whereas Westerners had a HR 1.45 (95% CI = 1.002 ± 2.09, P < 0.05). This might be due to discrepancy of muscle measurement and sarcopenia definition. Cirrhotic patients with sarcopenia suffered from poor quality of life and functional disability and increased infection and mortality.2 Recently, not only sarcopenia, but also combined obesity, which is called “sarcopenic obesity”, is known to be associated with higher rates of mortality and have a greater impact on physical function than either alone. The proposed mechanisms include increased pro-inflammatory cytokines, decreased physical activity, reduced protein synthesis, aging. Durand et al. suggested that MELD-sarcopenia scores combined with MELD and psoas muscle area scores were superior to MELD score alone in predicting prognosis of cirrhotic patients3. These results indicated that sarcopenia is an excellent predictor of organ allocation in liver transplant recipients. However, Tandon et al reported that the effect of Sarcopenia was significant in patients with low MELD scores (<15; P = 0.02), but not in patients with high MELD scores4. Therefore, sarcopenia seems to be an important prognostic factor and needs to be treated in early and intermediated stage rather than advanced liver cirrhosis. On the other hand, Van Vugt et al. reported that among patients with cirrhosis listed for liver transplantation in the Eurotransplant registry, MELD-sarcopenia combined scoring system had limited value in predicting waiting list mortality, although low skeletal muscle mass was significant related with mortality on the waiting list, particularly in patients who were listed with low priority based on a low MELD score5. In this competing risk analysis, mortality was significantly higher in patients with sarcopeniaM6 than in patients without sarcopeniaM (most frequently used for cancer patients), whereas no differences were observed for patients with and without sarcopeniaC (for liver transplant candidate)7. Since there are no universally accepted cut-off values to classify patients with sarcopenia, care should be taken when analyzing the effect of sarcopenia on prognosis in patients with cirrhosis.
Coverts and Overt Hepatic Encephalopathy
( Sang Gyune Kim ) 대한간학회 2019 Postgraduate Courses (PG) Vol.2019 No.1
Hepatic encephalopathy occurs in more than 10-20% of all cases of cirrhosis and is an important complication that degrades the quality of life. Overt hepatic encephalopathy is readily identifiable since it is apparently accompanied by disorientation or flapping tremor. On the other hand, covert hepatic encephalopathy means that only psychometric or neurophysiological abnormalities appear without signs of clinically obvious cognitive impairment. Covert hepatic encephalopathy includes minimal hepatic encephalopathy and West-Haven Criteria grade I hepatic encephalopathy (Table 1). Covert hepatic encephalopathy is being noticed more often and is regarded as an important disease that needs to be managed appropriately. It is identified up to 38-60% of cirrhosis tested. Recent studies revealed that covert hepatic encephalopathy significantly decrease the quality of life and diminish working ability in patients with compensated liver cirrhosis. Furthermore, it is strongly associated with increased risk of progression to overt hepatic encephalopathy.
( Sang Gyune Kim ),( Jeong-ju Yoo ),( Young Seok Kim ),( Bora Lee ),( Soung Won Jeong ),( Jae Young Jang ),( Sae Hwan Lee ),( Hong Soo Kim ),( Young Don Kim ),( Gab Jin Cheon ),( Boo Sung Kim ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1
Aims: To date, there is no acceptable criteria of spleen size for the clinical diagnosis of liver cirrhosis even though the recent Baveno consensus states splenomegaly is an adjunctive finding to define liver cirrhosis. We evaluated how relevant spleen volume (SV) measured by ultrasonography is to liver fibrosis stage and investigated the optimal cut-off of SV for liver cirrhosis. Methods: Total 431 patients whose SV was measured by ultrasonography (length x height x width x π/6) and got a liver biopsy for various reasons were included in this study. Spleen volume/body surface area (SV/BSA) in each patient was used for sensitivity analysis. Fibroscan score (kPa) was compared to SV for the relation with liver fibrosis stage. Clinical and laboratory findings were also collected. Results: The baseline characteristics of the patients were as follows: mean age (49.1±12.2), slightly male predominance (223/431, 51.7%), mean BSA (1.7±0.2 m2), most common etiology of liver disease is hepatitis B (190, 44.1%), mean MELD score (9.7±4.1), Child-Pugh class [(A/B/C, 339(78.7%)/75(17.4%)/17(3.9%)], fibrosis stage [F0/F1/F2/F3/F4, 35(8.1%)/40(9.3%)/69(16.0%)/56(12.99%)/231(53.6%)]. SV was significantly larger in young age (<40), male sex, viral hepatitis, high BSA, high MELD and Child-Pugh score. SV was also well correlated with fibroscan score (r=0.509, p<0.001). Mean SV (ml) according to fibrosis stage was F0 (169±59), F1 (189±99), F2 (198±82), F3 (236±79), F4 (457±283). AUROCs of SV and SV/SBA for predicting cirrhosis were 0.891 (95% confidence interval, 0.862-0.921), 0.905 (95% CI, 0.878-0.932). Optimal cut-off of SV and SV/SBA for the diagnosis of cirrhosis were 268ml, 161ml respectively. Conclusions: SV measured by ultrasonography was closely associated with severity of liver disease and fibrosis stage. SV measurement using ultrasonography is useful as a supplementary method for the diagnosis of liver cirrhosis.
( Sang Gyune Kim ),( Jeong Joo Yoo ),( Young Seok Kim ),( Bora Lee ),( Soung Won Jeong ),( Jae Young Jang ),( Sae Hwan Lee ),( Hong Soo Kim ),( Young Don Kim ),( Gab Jin Cheon ),( Boo Sung Kim ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1
Aims: Several real-time two-dimensional shear wave elastography (2D-SWE) have been developed to assess liver fibrosis with readily use of combining elastography and traditional ultrasound imaging. However, compared with transient elastography (fibroscan), the diagnostic accuracy and clinical usefulness of these methods were not fully validated. In this study, newly developed 2D-SWE (LOGIQ E9, GE healthcare, UK) was evaluated for predicting liver fibrosis stage and compared with fibroscan. Methods: Out of 1,395 patients who received 2D-SWE during May 2015 to Apr 2016, seventy (5.0%) who failed to get available value of 2D-SWE due to obesity and 131 (9.4%) with high value of AST or ALT were excluded in the analysis. Liver biopsy was performed in 177 patients. 2D-SWE measurement was considered valid when homogenous color pattern in a region of interest of at least 10 mm was shown at 10 different sites. Diagnostic performance was calculated using area under the receiver operating characteristics curve (AUROC). Results: Patients were male predominant (60.8%), their mean age was 50.4±12.4 years old and most common etiology of liver disease was hepatitis B (40.3%) followed by alcohol (26.1%). Liver fibrosis stage consisted of F0 (14.1%), F1 (12.4%), F2 (28.8%), F3 (18.1%) and F4 (26.6%). Overall, 2D-SWE was well correlated with transient elastography (r=0.788, P<0.001). 2D-SWE median values (kPa) increased with increasing stage of liver fibrosis [ F0 (5.0±1.5), F1 (6.4±2.3), F2 (6.5±2.0), F3 (9.0±2.7), F4 (12.7±2.9)] (p for trend <0.001). For the diagnosis of liver cirrhosis, AUROCs and optimal cutoff of 2D-SWE were 0.928 (95% confidence interval [CI], 0.890-0.967) and 10.1 kPa. The sensitivity, specificity, positive predictive value and negative predictive value for predicting cirrhosis were 82.2%, 92.2%, 78.7% and 93.7% respectively. For diagnosing significant liver fibrosis (≥F2), AUROCs and optimal cutoff of 2D-SWE were 0.913 (95% CI, 0.870-0.956) and 7.99 kPa. Conclusions: With effective comparability to fibroscan and availability of a conventional ultrasound examination, 2D-SWE is an useful tool for stratifying liver fibrosis stage and diagnosing liver cirrhosis.