Ultrazvočna preiskava mišice psoas za oceno sarkopenije, zapletov in preživetja bolnikov z jetrno cirozo

Hari, Andrej (author), Štabuc, Borut (mentor)

IZVLEČEK Namen dela: Sarkopenija pomembno vpliva na zaplete in preživetje bolnikov z jetrno cirozo. Zato bi bilo smiselno stopnjo sarkopenijo vključiti med MELD (lestvica za oceno jetrne odpovedi, ang. Model of end liver disease) kazalce s katerimi se razvršča bolnike na listo za presaditev jeter. Sarkopenijo lahko ugotovimo z MRI ali CT merjenjem volumna skeletne mišične mase v trebušni votlini. V raziskavi želimo ugotoviti ali je mogoče z ultrazvočno preiskavo premera mišice psoas in izračunom kliničnih kazalcev mišične mase oceniti sarkopenijo in vpliv sarkopenije na zaplete in preživetje pri bolnikih z jetrno cirozo. Cilji/hipoteze: Z ultrazvočno meritvijo premera mišice psoas pri bolnikih z  jetrno cirozo lahko ocenimo stopnjo  sarkopenije. Tako opredeljena sarkopenija je prognostični dejavnik za preživetje in za nastanek zapletov pri bolnikih z jetrno cirozo. Utemeljitev: Slaba prehranjenost in sarkopenija sta pomemben dejavnik za nastanek zapletov jetrne ciroze. Splošno stanje telesne prehranjenosti, še posebej sarkopenijo, je v vsakodnevni klinični praksi pri bolnikih z jetrno cirozo težko oceniti. Objektivno jo lahko ocenimo s CT ali MRI meritvami volumna oziroma ploščine skeletne mišične mase v trebušni votlini. Zaradi sevanja oziroma težje dostopnosti se v praksi CT ali MRI meritve mišične mase redko uporabljajo. Objektivna ocena sarkopenije s pomočjo ultrazvočne preiskave je enostavna in ponovljiva metoda, ki bi lahko ob dosedanji oceni MELD vplivala na razvrščanje bolnikov na listo za presaditev. Obenem bi lahko predstavljala napovedni dejavnik za zaplete jetrne ciroze, potrebo po hospitalizacijah in preživetje bolnikov z jetrno cirozo. Zasnova raziskave, opis metod in preiskovancev: Pri 75 zaporednih bolnikih z dekompenzirano jetrno cirozo, ki so opravili ultrazvočni pregled med januarjem 2016 in novembrom 2017 v naši bolnišnici, smo opravili retrospektivno analizo prospektivno zbranih podatkov. Dekompenzacijo jetrne ciroze smo pri bolnikih s potrjeno jetrno cirozo opredelili kot pojav ene ali več oblik dekompenzacije - pojav ascitesa, okužbe, hepatične encefalopatije, zlatenice ali varikozne krvavitve. Vse bolnike smo razvrstili po Child –Pughovi klasifikaciji. Pri vseh bolnikih smo ultrazvočno izmerili premer mišice psoas, določili preiskovančevo starost, spol, višino, telesno težo, indeks telesne mase in opredelili za raziskavo pomembne laboratorijske kazalce. Možnost uporabe ultrazvočne meritve mišice psoas smo preverili z odstotkom ponovljivosti zanesljive meritve premera mišice psoas in z oceno variabilnosti meritve. Premer mišice psoas smo pretvorili v ultrazvočni kazalec razmerja premera psoasa in telesne višine (ang. psoas-to-height-ratio; US-PTHR) in v kazalec psoas-mišica (ang. psoas-muscle-index; US-PMI). Za oceno vpliva izračunanih ocen sarkopenije na pojav dekompenzacije in umrljivosti smo uporabili Coxovo analizo z upoštevanjem več faktorske analize neodvisnih spremenljivk študijske skupine. Rezultate smo primerjali s skupino zdravih prostovoljcev.   Rezultati. Ultrazvočna meritev premera mišice psoas je bila uspešna in zanesljiva pri vseh subjektih v kontrolni skupini in pri 54 (72%) od 75 vključenih bolnikov z dekompenzirano jetrno cirozo. Pri bolnikih je bila povprečna vrednost US-PTHR 20 mm/m (rang: 13-26; IQR 3 mm/m) in povprečna vrednost US-SMI 3.2 cm2/m2 (rang: 1.2-5.5, IQR 1.0 cm2/m2). V kontrolni skupini je bila povprečna vrednost US-PTHR 24 mm/m (rang: 20-28; IQR 2 mm/m) in povprečna vrednost US-SMI 4.5 cm2/m2 (rang: 3.2-6,0; IQR 0.8 cm2/m2). Mediana opazovanja bolnikov je znašala 11,7 mesecev. V tem obdobju je 37 (68.5%) bolnikov potrebovalo hospitalizacijo zaradi ponovne dekompenzacije bolezni. 15 (27.8) bolnikov je umrlo, od tega 12 zaradi vzrokov povezanih z jetrno cirozo. US-PTHR je bil značilno povezan s hospitalizacijo (p<0.0001; HR 0.717; 95% CI: 0.622- 0.828), kakor tudi US-SMI (p<0.0001, HR 0.881; 95% CI: 0.836-0.929). US-PTHR je bil značilno povezan s smrtnostjo (p=0.022; HR 0.825; 95% CI: 0.701-0.973), kakor tudi US-SMI (p=0.017; HR 0.930; 95% CI: 0.876-0.987). Zaključek. Ultrazvočna meritev mišice psoas je uporabna in zanesljiva pri približno 70% bolnikov z dekompenzirano jetrno cirozo. Ultrazvočno zasnovan izračun kazalcev skeletne mišične mase ima napovedno vrednost za pojav hospitalizacije in smrtnosti pri tej skupini bolnikov. Ultrazvočna meritev premera mišice psoas bi lahko predstavljala preprosto obposteljno metodo za stratifikacijo ogroženosti v tej populaciji.

• Language: Slovenian
• Keywords: izguba mišične mase, neinvazivna diagnoza, kazalec razmerje premera psoasa in telesne višine, kazalec psoas-mišica
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2020
• PID: 20.500.12556/RUL-116863
• COBISS.SI-ID: 21498627
• Publication date in RUL: 14.06.2020

Secondary language

• Language: English
• Title: Muscle psoas indices measured by ultrasound in liver cirrhosis – possible use in sarcopenia assessment and their predictive value of liver decompensation and mortality

Abstract

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.

• Keywords: muscle mass loss, non-invasive diagnosis, Psoas to height ratio, Psoas muscle index