Survival benefit of l-carnitine supplementation in patients with cirrhosis.

BACKGROUND: l-Carnitine supplementation is effective in improving muscle cramps, hyperammonemia, and hepatic encephalopathy in patients with cirrhosis. However, limited evidence is available on the effect of l-carnitine supplementation on the survival of patients with cirrhosis. METHODS: In this retrospective study, 674 patients with cirrhosis admitted to Gifu University Hospital or Chuno Kosei Hospital between October 2011 and December 2018 were enrolled. l-carnitine supplementation was defined as the use of l-carnitine for >30 consecutive days during the follow-up period. Propensity score matching was applied to create comparable groups between l-carnitine-treated and untreated patients. Mortality was evaluated using the Cox proportional hazards model. RESULTS: Among the patients, 93 were excluded. Of the remaining 581 patients, 71 (12%) received l-carnitine supplementation. Propensity matching identified 189 patients (63 l-carnitine-treated and 126 untreated patients) with comparable baseline characteristics in both groups. Of the matched patients, 33 (52%) l-carnitine-treated and 74 (59%) untreated patients died during the median follow-up period of 36.3 months. Overall survival was significantly higher in l-carnitine-treated patients than in untreated patients (hazard ratio [HR], 0.66; 95% CI, 0.43-0.99). A subgroup analysis showed that the survival benefit of l-carnitine supplementation was prominent in patients with Child-Pugh Class B or C (HR, 0.39; 95% CI, 0.23-0.68), serum albumin levels ≤3.5 g/dl (HR, 0.59; 95% CI, 0.37-0.95), and ammonia levels ≥90 mcg/dl (HR, 0.50; 95% CI, 0.26-0.97), and in those without sarcopenia (HR, 0.56; 95% CI, 0.35-0.90). CONCLUSION: l-Carnitine supplementation may improve survival in patients with cirrhosis.

Usefulness of the Trabecular Bone Score in Assessing the Risk of Vertebral Fractures in Patients with Cirrhosis.

The trabecular bone score (TBS), a surrogate measure of bone microarchitecture, provides complementary information to bone mineral density (BMD) in the assessment of osteoporotic fracture risk. This cross-sectional study aimed to determine whether TBS can identify patients with liver cirrhosis that are at risk of vertebral fractures. We enrolled 275 patients who completed evaluations for lumbar BMD, TBS, and vertebral fractures between November 2018 and April 2021. BMD was measured using dual-energy X-ray absorptiometry (DXA), TBS was calculated by analyzing DXA images using TBS iNsight software, and vertebral fractures were evaluated using Genant's semi-quantitative method with lateral X-ray images. Factors associated with vertebral fractures and their correlation with the TBS were identified using regression models. Of the enrolled patients, 128 (47%) were female, the mean age was 72 years, and 62 (23%) were diagnosed with vertebral fractures. The prevalence of vertebral fractures was higher in women than in men (33% vs. 14%; p < 0.001). The unadjusted odds ratio (OR) of the vertebral fractures for one standard deviation decrease in TBS and BMD was 2.14 (95% confidence interval [CI], 1.69−2.73) and 1.55 (95% CI, 1.26−1.90), respectively. After adjusting for age, sex, and BMD, the adjusted OR of the vertebral fractures in TBS was 2.26 (95% CI, 1.52−3.35). Multivariate linear regression analysis showed that TBS was independently correlated with age (ß = −0.211), body mass index (ß = −0.251), and BMD (ß = 0.583). TBS can help identify patients with cirrhosis at risk of vertebral fractures.

Usefulness of nutritional therapy recommended in the Japanese Society of Gastroenterology/Japan Society of Hepatology evidence-based clinical practice guidelines for liver cirrhosis 2020.

BACKGROUND: The JSGE/JSH guidelines for the management of patients with liver cirrhosis revised in 2020 recommends new strategies for nutritional assessment and intervention, although their usefulness in daily clinical practice is unclear. METHODS: A total of 769 patients with cirrhosis were classified into low-, intermediate-, and high-risk groups according to hypoalbuminemia and sarcopenia, the criteria established for initiating the nutritional therapy algorithm in the guidelines. The association between these groups and mortality was analyzed using a Cox proportional hazards model. The effect of branched-chain amino acids (BCAAs) on survival was evaluated using propensity score matching. RESULTS: Of the enrolled patients, 495 (64%) were men with a median age of 73 years, 428 (56%) had hypoalbuminemia, 156 (20%) had sarcopenia, and 288 (37%) were receiving BCAAs. During a median follow-up period of 1.5 years, 276 (36%) patients died. The intermediate-risk [hazard ratio (HR), 1.60; 95% confidence interval (CI), 1.18-2.18] and high-risk (HR, 2.85; 95% CI, 1.92-4.23) groups independently predicted mortality. Among the propensity score-matched 250 patients, 49 (39%) BCAA-treated and 58 (46%) untreated died. Overall survival was higher in BCAA-treated patients than in untreated patients (HR, 0.67; 95% CI, 0.46-0.98). The survival benefit of BCAAs was pronounced in the intermediate-risk (HR, 0.50; 95% CI, 0.31-0.80) and high-risk (HR, 0.38; 95% CI, 0.16-0.91) groups. CONCLUSIONS: The 2020 JSGE/JSH guidelines for liver cirrhosis are useful in stratifying the mortality risk and providing effective nutritional interventions for malnourished patients with cirrhosis.

Sarcopenia impairs prognosis of patients with liver cirrhosis.

OBJECTIVE: Sarcopenia is characterized by the loss of skeletal muscle mass, and is reported to appear in patients with liver cirrhosis (LC). The aim of this study was to investigate the prevalence of sarcopenia in patients with LC, and to test the association between sarcopenia and patient outcomes. We also analyzed the effect of branched-chain amino acid (BCAA) supplementation on sarcopenic LC. METHODS: Clinical and blood biochemical data of 130 patients with LC who underwent abdominal computed tomography scan were analyzed in this retrospective study. The cross-sectional area of skeletal muscles was measured at the level of the third lumbar vertebra on the scan. The skeletal muscle index was calculated to identify sarcopenia. Cirrhotic patients who were treated with BCAA supplementation of 12 g/d for ≥ 1 y were defined as the BCAA group, and the effect of BCAA on sarcopenic LC was evaluated. RESULTS: Sixty-eight percent of all patients (82% of men and 50% of women) were diagnosed with sarcopenia. Male sex (P = 0.01) and body mass index (P < 0.0001) were predictors of sarcopenia. The multivariate Cox proportional hazards model found BCAA supplementation (hazard ratio [HR], 0.38; P = 0.01), sarcopenia (HR, 3.03; P < 0.01), and Child-Pugh classes B (HR, 2.39; P = 0.03) and C (HR, 5.49; P < 0.001) to be independently associated with mortality. The mortality of sarcopenic LC was significantly higher than that of non-sarcopenic LC (P = 0.01). Moreover, BCAA supplementation improved the survival of sarcopenic patients in subgroup analysis (P < 0.01). CONCLUSIONS: Sarcopenia is significantly associated with mortality in patients with LC. BCAA supplementation might be associated with improved survival of such patients.