Original ArticlesBioelectrical impedance analysis is a useful bedside technique to assess malnutrition in cirrhotic patients with and without ascites☆
Abstract
Protein-calorie malnutrition is associated with poor prognosis in chronic liver disease, but reliable assessment is hampered by changes in body water. We prospectively evaluated the effect of fluid retention on bioelectrical impedance analysis (BIA) as a simple method for the estimation of body cell mass (BCMBIA) in 41 patients with cirrhosis (n = 20 with ascites; n = 21 without ascites) using total body potassium counting (BCMTBP) as a reference method. Arm muscle area and creatinine-derived lean body mass were compared with total body potassium data. In patients total body potassium was 24.4% lower than in controls and this loss was more severe in patients with ascites (−34.1%; P < .01). BCMBIA and BCMTBP were closely correlated in controls (r2 = .87, P < .0001), patients without ascites (r2 = .94, P < .0001) and patients with ascites (r2 = .56, P < .0001). Removal of 6.2 ± 3 L of ascites had only minor effects on BCMBIA (deviation of −0.18 kg/L ascites). Limits of agreement between both methods were wider in patients with ascites than in patients without (6.2 vs. 4.2 kg). In patients without ascites arm muscle area (r2 = .64; P < .001) and lean body mass (r2 = .55; P < .001) correlated significantly with total body potassium, but not in patients with ascites. For assessment of protein malnutrition in patients with cirrhosis, body cell mass determination by use of BIA offers a considerable advantage over other widely available but less accurate methods like anthropometry or the creatinine approach. Despite some limitations in patients with ascites, BIA is a reliable bedside tool for the determination of body cell mass in cirrhotic patients with and without ascites. (Hepatology2000;32:1208-1215.)
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Nutrition in liver disease
2023, Comprehensive Guide to Hepatitis AdvancesThe important role of nutrition in the trajectory of chronic liver disease has long been recognized as exemplified by the fact that nutritional status was one of the variables of the original prognostic score introduced by Child and Turcotte. Yet, not all hepatologists consider nutrition issues relevant in the management of their patients. In this chapter, the scientific and evidence base for nutritional metabolic management in patients with liver disease is reviewed including appropriate recommendations.
Comparison of Anthropometry, Bioelectrical Impedance, and Dual-energy X-ray Absorptiometry for Body Composition in Cirrhosis
2022, Journal of Clinical and Experimental HepatologyThis study was planned to evaluate triceps skinfold thickness (TSFT), mid-arm muscle circumference (MAMC) and bioelectrical impedance analysis (BIA) for assessing body composition using dual-energy X-ray absorptiometry (DEXA) (reference) and to predict fat mass (FM) and fat-free mass (FFM) in patients with cirrhosis.
FM and FFM were assessed by using DEXA and BIA. Skin-fold calliper was used for measuring TSFT, and MAMC was calculated. Bland–Altman plot was used to determine agreement and linear regression analysis for obtaining equations to predict FM and FFM.
Patients with cirrhosis (n = 302, 241 male, age 43.7 ± 12.0 years) were included. Bland–Altman plot showed very good agreement between BIA and DEXA for the estimation of FM and FFM. Majority of patients were within the limit of agreement: FM (98%) and FFM (96.4%). BIA shows a positive correlation with DEXA:FM (r = 0.73, P ≤ 0.001) and FFM (r = 0.86, P ≤ 0.001). DEXA (FM and FFM) shows a positive correlation with TSFT (r = 0.69, P ≤ 0.01) and MAMC (r = 0.61, P ≤ 0.01). The mean difference between the observed and predicted value of FM and FFM by BIA in the developmental set was 0.01 and 0.05, respectively; whereas in the validation set, it was −0.13 and 0.86, respectively. The mean difference between the observed and predicted value of TSFT and MAMC in the developmental set was 0.43 and 0.07; whereas, in the validation set, it was 0.16 and 0.48, respectively.
Anthropometry (TSFT and MAMC) and BIA are simple and easy to use and can be a substitute of DEXA for FM and FFM assessment in routine clinical settings in patients with cirrhosis.
Malnutrition and Alcohol-Associated Hepatitis
2021, Clinics in Liver DiseaseCitation Excerpt :It is the ratio of measured 24-hour urine creatinine excretion in a patient compared with expected excretion in a normal individual of the same sex and height. A study by Pirlich and coworkers3 showed a strong correlation between muscle cell mass as assessed by creatinine and body cell mass as assessed by total body potassium count. Liver dysfunction did not alter urinary creatinine, but renal dysfunction did.
New anthropometric and biochemical models for estimating appendicular skeletal muscle mass in male patients with cirrhosis
2021, NutritionThe use of easily accessible methods to estimate skeletal muscle mass (SMM) in patients with cirrhosis is often limited by the presence of edema and ascites, precluding a reliable diagnosis of sarcopenia. The aim of this study was to design predictive models using variables derived from anthropometric and/or biochemical measures to estimate SMM; and to validate their applicability in diagnosing sarcopenia in patients with cirrhosis.
Anthropometric and biochemical data were obtained from 124 male patients (18–76 y of age) with cirrhosis who also underwent dual-energy x-ray absorptiometry (DXA) and handgrip strength (HGS) assessments to identify low SMM and diagnose sarcopenia using reference cutoff values. Univariate analyses for variable selection were applied to generate predictive decision tree models for low SMM. Model accuracy for the prediction of low SMM and sarcopenia (when associated with HGS) was tested by comparison with reference cutoff values (appendicular SMM index, obtained by DXA) and clinical sarcopenia diagnoses. The prognostic value of the models for the prediction of sarcopenia and mortality at 104 wk of follow up was further tested using Kaplan–Meier graphics and Cox models.
The models with anthropometric variables, alone and combined with biochemical variables, showed good accuracy (0.89 [0.83; 0.94] and 0.90 [0.84; 0.95], respectively) and sensitivity (0.72 [0.56; 0.85] and 0.74 [0.59; 0.86], respectively) and excellent specificity (0.96 [0.90; 0.99] and 0.97 [0.92; 0.99], respectively) in predicting SMM. Both models showed excellent accuracy (0.94 [0.89; 0.98], good sensitivity (0.68 [0.45; 0.86]), and excellent specificity (1.00 [0.96; 1.00]) in predicting sarcopenia. The models predicted mortality in patients with sarcopenia, with the likelihood of death sixfold greater relative to patients not predicted to have sarcopenia.
Our simple and inexpensive models provided a practical and safe approach to diagnosing sarcopenia patients with cirrhosis along with an estimate of their mortality risk when other reference methods are unavailable.
Evaluation of malnutrition risk of inpatients in a research and training hospital: A cross-sectional study
2021, Clinical Nutrition ESPENMalnutrition is one of the most important factors affecting the prognosis of inpatients. The aim of this study is to determine the malnutrition risk of hospitalized patients and to examine the relationship between the presence of malnutrition and other parameters.
The study included 162 inpatients over the age of 25 who were staying in the hospital's internal medicine service for 7 days or more and who volunteered to participate in the study. A demographic-information questionnaire, consisting of 5 sections, a 24-h food recall record, NRS-2002, NRI and Beck Depression Inventory was given to patients during bedside interviews. After obtaining the necessary permission, the anthropometric measurements and biochemical parameter values of the patients were taken from their files. All statistical analyzes were performed by researchers with the SPSS package program.
Of 162 patients (48.8% female, 51.2% male), 24.7% were at risk for malnutrition according to NRS-2002 and 66.7% of the patients were not depressive, based on the Beck Depression Inventory scale. The malnutrition risk was higher (60.0%) in patients who had been hospitalized for more than 15 days (p = 0.010). The majority of those with malnutrition had no problems preventing them from eating (32.5%), were found to be not depressive (52.5%) and were in the normal range of body mass index (57.5%) (p = 0.002, p = 0.034, p = 0.001; respectively). Nutrient intake was lower in patients with a higher malnutrition risk, but the difference was insignificant (p > 0.05). Albumin levels (p = 0.028) and total protein levels (p = 0.015) were significantly lower in patients who were at risk of malnutrition. While overweight patients showed higher levels of serum albumin (p < 0.001), CRP levels were found to be lower in overweight patients (p < 0.001).
It was found that the majority of patients with malnutrition were in the normal range for BMI. Nutritional intake and biochemical parameters should be followed closely in patients who are at risk of malnutrition. Depression can be a cause for insufficient nutrition and should be evaluated, particularly in patients whose length of hospital stay is greater than 7 days.
Validation of a new prognostic body composition parameter in cancer patients
2021, Clinical NutritionEstimation errors associated with bioelectric impedance evaluation may affect the accuracy of body composition and its prognostic value. We evaluated the prognostic value of a new body composition parameter (Nutrigram®) obtained from bioimpedance vectorial analysis-derived body cell mass and its association with nutritional and functional status.
Data of Italian and German cancer patients observed prospectively until death were used. Multivariable models (adjusted for age, gender, hydration status, performance status, and disease's stage) were built in both cohorts to assess the association between body composition outcome parameters (low fat-free mass [FFM], <15 [females] and <17 [males] kg/m2; low standardized phase angle [SPA], <−1.65; low Nutrigram®, <510 [females] and <660 [males] mg/24 h/m) and 1-year all-cause mortality, low body mass index (BMI; <20 [<70 years] and <22 [≥70 years] kg/m2), clinically significant weight loss (WL; ≥10% in 6 months) and low handgrip strength (HG; <20 [females] and <30 [males] kg).
Low Nutrigram® was independently associated with mortality in both Italian (HR = 1.84 [95%CI, 1.18–2.86]; P = 0.007) and German cohorts (HR = 1.52 [95%CI, 1.17–2.07]; P = 0.008). Low FFMI and low SPA did not predict survival in the German cohort. In patients with low Nutrigram®, worse nutritional and functional status were observed in both study populations. Performance of models addressing the study endpoints showed substantial consistency with both cohorts, particularly of those including low Nutrigram®.
We validated a new prognostic body composition parameter, which is easier to interpret than standard nutritional parameters and may be useful for identifying cancer patients at nutritional risk, requiring early nutritional support.
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Dr. M. Pirlich was supported by the Else Kröner-Fresenius-Stiftung, Bad Homburg, Germany.