ABSTRACT
Background: Sarcopenia significantly affects the complications and survival of patients with liver cirrhosis. Therefore, it would be reasonable to include sarcopenia among MELD (Model of end liver disease) indices to better prioritize patients on the liver transplant waiting list. Sarcopenia can be detected by MRI (Magnetic resonance imaging) or CT (Computed tomography) measurements of the skeletal muscle area or volume in the abdominal cavity. This study aims to determine whether sarcopenia and its impact on complications and survival in patients with liver cirrhosis can be evaluated by ultrasound psoas muscle measurement and subsequent calculation of clinical muscle mass indices.
Aims and hypotheses: Ultrasound measurement of psoas muscle diameter in patients with liver cirrhosis can assess the degree of sarcopenia. Thus defined sarcopenia is a prognostic factor for survival and complications in patients with liver cirrhosis.
Rationale: Malnutrition and sarcopenia are important factors in the development of liver cirrhosis complications. The malnutrition, especially sarcopenia, is difficult to assess in everyday clinical practice in patients with liver cirrhosis. It can be objectively evaluated by CT or MRI measurements of the abdominal skeletal muscle volume or surface area. Because of iradiation or inaccessibility, such measurements are rarely used in clilnical practice. An objective assessment of sarcopenia by ultrasound is simple and reproducible method that could affect the classification of patients on the liver transplant waiting list. At the same time, it could represent a predictive model of liver cirrhosis complications such as the need for hospitalization and survival.
Methods and study design: A retrospective analysis of prospectively collected data was performed in 75 consecutive patients with decompensated liver cirrhosis who underwent ultrasound examination between January 2016 and November 2017 at our hospital. Liver cirrhosis decompensation was defined in patients with confirmed liver cirrhosis as the occurrence of one or more types of decompensation - the occurrence of ascites, infection, hepatic encephalopathy, jaundice or varicose bleeding. All patients were classified according to the Child – Pugh classification. All patients underwent ultrasound measurements of the psoas muscle diameter. Simultaneously, we determined the patient's age, sex, height, weight, body mass index, and identified laboratory data important for the study. The applicability of ultrasond psoas measurement was verified. The psoas muscle diameter was converted into the ultrasound psoas-to-height-ratio index (US-PTHR) and into the ultrasound psoas-muscle-index (US-PMI). Multifactorial Cox analysis was used to evaluate independent study group variables and to assess the impact of calculated sarcopenia estimates on the onset of decompensation and mortality,. The results were compared with those of the control group consisted of healthy volunteers.
Results. Ultrasound measurement of psoas muscle diameter was successful and reliable in all subjects in the control group and in 54 (72%) of the 75 enrolled patients with decompensated liver cirrhosis. In patients, the mean US-PTHR was 20 mm/m (range: 13-26; IQR 3 mm/m) and the mean US-SMI was 3.2 cm2/m2 (range: 1.2-5.5, IQR 1.0 cm2/m2). In the control group, the average US-PTHR value was 24 mm/m (range: 20-28; IQR 2 mm/m) and the average US-SMI value was 4.5 cm2/m2 (range: 3.2-6.0; IQR 0.8 cm2/m2). Restricted mean survival time was 11.7 months. During this period, 37 (68.5%) patients needed hospitalization due to further decompensation of the disease. 15 (27.8%) patients died, 12 of them due to liver cirrhosis related causes. US-PTHR was significantly associated with hospitalization (p <0.0001; HR 0.717; 95% CI: 0.622- 0.828) as well as US-SMI (p <0.0001; HR 0.881; 95% CI: 0.836-0.929). US-PTHR was significantly associated with mortality (p = 0.022; HR 0.825; 95% CI: 0.701-0.973) as well as US-SMI (p = 0.017; HR 0.930; 95% CI: 0.876-0.987).
Conclusion. Ultrasound psoas muscle measurement is useful and reliable in approximately 70% of patients with decompensated liver cirrhosis. The ultrasound-based calculation of skeletal muscle indices has a predictive value for the incidence of further hospitalization and mortality in this group of patients. Ultrasound measurement of psoas muscle diameter could represent a simple bedside method for risk stratification in this population.
|
