Different combinations of the GLIM criteria for patients awaiting a liver transplant: Poor performance for malnutrition diagnosis but a potentially useful prognostic tool.

BACKGROUND & AIMS: Studies using the Global Leadership Initiative on Malnutrition (GLIM) criteria for patients with liver cirrhosis are limited. This study aimed to assess the impact of malnutrition according to the GLIM criteria on the outcomes of patients awaiting a liver transplant (LTx) and compare these criteria with Subjective Global Assessment (SGA). METHODS: This retrospective observational study included adult patients awaiting LTx. Patient clinical data, nutritional status according to various tools including SGA, and resting energy expenditure were assessed. The distinct phenotypic and etiologic criteria provided 36 different GLIM combinations. The GLIM criteria and SGA were compared using the kappa coefficient. The variables associated with mortality before and after the LTx and with a longer length of stay (LOS) after LTx (≥18 days) were assessed by Cox regression and logistic regression analyses, respectively. RESULTS: A total of 152 patients were included [median age 52.0 (interquartile range: 46.5-59.5) years; 66.4% men; 63.2% malnourished according to SGA]. The prevalence of malnutrition according to the GLIM criteria ranged from 0.7% to 30.9%. The majority of the GLIM combinations exhibited poor agreement with SGA. Independent predictors of mortality before and after LTx were presence of ascites or edema (p = 0.011; HR:2.58; CI95%:1.24-5.36), GLIM 32 (PA-phase angle + MELD) (p = 0.026; HR:2.08; CI95%:1.09-3.97), GLIM 33 (PA + MELD-Na≥12) (p = 0.018; HR:2.17; CI95%:1.14-4.13), and GLIM 34 (PA + Child-Pugh) (p = 0.043; HR:1.96; CI95%:1.02-3.77). Malnutrition according to GLIM 28 (handgrip strength + Child-Pugh) was independently associated with a longer LOS (p = 0.029; OR:7.21; CI95%:1.22-42.50). CONCLUSION: The majority of GLIM combinations had poor agreement with SGA, and 4 of the 36 GLIM combinations were independently associated with adverse outcomes.

Bioelectrical impedance vector analysis in patients on the waiting list for liver transplant: Associated factors and prognostic effects.

OBJECTIVES: The aim of this study was to assess patients on the waiting list for liver transplant (LTx) according to bioelectrical impedance vector analysis (BIVA), as well as to verify the association between the placement of the vectors on the graph with clinical outcomes and identify the predictors to vector placement in quadrant 4 (Q4; indicating more hydration and less cellularity). METHODS: This was a retrospective observational study including 129 patients ≥20 y of age awaiting LTx. Patients' nutritional status was assessed by using different tools, including single-frequency bioelectrical impedance analysis and the Subjective Global Assessment (SGA). Clinical data were registered. The BIVA was evaluated by comparing the individual vectors plotted for all patients to the tolerance ellipses of 50%, 75%, and 95% of the reference healthy population. The quadrant of the vector for each patient was registered. RESULTS: The majority of the vectors were placed in Q1 (n = 54; 41.9%) and Q4 (n = 39; 30.2%). The presence of ascites or edema (hazard ratio [HR], 2.43; 95% confidence interval [CI], 1.15-5.12; P = 0.019) and the BIVA vector placed in Q4 in any ellipse (HR, 2.10; 95% CI, 1.07-4.09; P = 0.029) were independent predictors for mortality on the waiting list or ≤1 y after LTx. BIVA was not associated with longer hospital length of stay. The predictors of vector placement in Q4 were higher age, malnutrition according to SGA, and presence of ascites or edema. CONCLUSION: Patients on the waiting list for LTx with BIVA vectors placed in Q4, in the 50%, 75%, or 95% tolerance ellipses, presented a worse prognosis.

Energy Balance and Nutrition Status: A Prospective Assessment of Patients Undergoing Liver Transplantation.

BACKGROUND: Energy balance (EB) and its relation to nutrition status throughout the perioperative period of liver transplantation (LTx) patients has been poorly reported in the literature, and this is the primary objective of the current study. METHODS: A prospective observational study was conducted with patients undergoing LTx, who were assessed before and after the operation. Resting energy expenditure, total energy expenditure (TEE), dietary intake, and EB were evaluated, as well as anthropometry, handgrip strength, and standard phase angle (SPA). The presence of complications after the operation, length of intensive care unit and hospital stay, and death were registered. A P-value < 0.05 was considered statistically significant. RESULTS: The average age was 54.1 ± 11.5 years; 79.3% of the patients were male, and the mean model for end-stage liver disease (MELD) score was 16.7 ± 4.6. Negative EB was seen in 71.4% and 77.8% of patients before and after LTx, respectively. Food intake further decreased after the operation, leading to a significantly more negative EB. The prevalence of malnutrition ranged from 17.2% to 57.7% pretransplantation and 30.8% to 86.4% postoperatively, according to the different methods used. Increased preoperative TEE (0.040) and age (0.039) were predictive factors for complications, and low SPA was a predictive factor of death (0.038). CONCLUSION: Negative EB was prevalent, and this was associated with high rates of malnutrition. These data reinforce the importance of individual nutrition assessment, including dietary intake, to tailor early nutrition interventions.

SARCOPENIA, OBESITY AND SARCOPENIC OBESITY IN LIVER TRANSPLANTATION: A BODY COMPOSITION PROSPECTIVE STUDY.

BACKGROUND: Sarcopenia is prevalent before liver transplantation, and it is considered to be a risk factor for morbidity/mortality. After liver transplantation, some authors suggest that sarcopenia remains, and as patients gain weight as fat, they reach sarcopenic obesity status. AIM: Prospectively to assess changes in body composition, prevalence and associated factors with respect to sarcopenia, obesity and sarcopenic obesity after transplantation. METHODS: Patients were evaluated at two different times for body composition, 4.0±3.2y and 7.6±3.1y after transplantation. Body composition data were obtained using bioelectrical impedance. The fat-free mass index and fat mass index were calculated, and the patients were classified into the following categories: sarcopenic; obesity; sarcopenic obesity. RESULTS: A total of 100 patients were evaluated (52.6±13.3years; 57.0% male). The fat-free mass index decreased (17.9±2.5 to 17.5±3.5 kg/m2), fat mass index increased (8.5±3.5 to 9.0±4.0; p<0.05), prevalence of sarcopenia (19.0 to 22.0%), obesity (32.0 to 37.0%) and sarcopenic obesity (0 to 2.0%) also increased, although not significantly. The female gender was associated with sarcopenia. CONCLUSION: The fat increased over the years after surgery and the lean mass decreased, although not significantly. Sarcopenia and obesity were present after transplantation; however, sarcopenic obesity was not a reality observed in these patients.

Sarcopenia, obesity and sarcopenic obesity in liver transplantation: a body composition prospective study / Sarcopenia, obesidade e obesidade sarcopênica em pacientes submetidos ao transplante hepático: estudo prospectivo de composição corporal

ABSTRACT Background: Sarcopenia is prevalent before liver transplantation, and it is considered to be a risk factor for morbidity/mortality. After liver transplantation, some authors suggest that sarcopenia remains, and as patients gain weight as fat, they reach sarcopenic obesity status. Aim: Prospectively to assess changes in body composition, prevalence and associated factors with respect to sarcopenia, obesity and sarcopenic obesity after transplantation. Methods: Patients were evaluated at two different times for body composition, 4.0±3.2y and 7.6±3.1y after transplantation. Body composition data were obtained using bioelectrical impedance. The fat-free mass index and fat mass index were calculated, and the patients were classified into the following categories: sarcopenic; obesity; sarcopenic obesity. Results: A total of 100 patients were evaluated (52.6±13.3years; 57.0% male). The fat-free mass index decreased (17.9±2.5 to 17.5±3.5 kg/m2), fat mass index increased (8.5±3.5 to 9.0±4.0; p<0.05), prevalence of sarcopenia (19.0 to 22.0%), obesity (32.0 to 37.0%) and sarcopenic obesity (0 to 2.0%) also increased, although not significantly. The female gender was associated with sarcopenia. Conclusion: The fat increased over the years after surgery and the lean mass decreased, although not significantly. Sarcopenia and obesity were present after transplantation; however, sarcopenic obesity was not a reality observed in these patients.

RESUMO Racional: A sarcopenia é prevalente antes do transplante de fígado e é considerada fator de risco para morbidade/mortalidade desses pacientes. Após o transplante hepático, alguns autores sugerem que a sarcopenia permanece, e os pacientes ganham peso na forma de gordura, atingindo o status de obesidade sarcopênica. Objetivo: Avaliar prospectivamente as mudanças na composição corporal, prevalência e fatores associados em relação à sarcopenia, obesidade e obesidade sarcopênica após o transplante. Métodos: Os pacientes foram avaliados em dois momentos diferentes para composição corporal, 4,0±3,2 e 7,6±3,1 anos e após o transplante. Os dados da composição corporal foram obtidos por meio de bioimpedância elétrica. O índice de massa livre de gordura e o índice de massa gorda foram calculados, e os pacientes foram classificados nas seguintes categorias: sarcopênico; obesidade; obesidade sarcopênica. Resultados: Foram avaliados 100 pacientes (52,6±13,3 anos; 57,0% homens). A prevalência de sarcopenia (19,0% para 22,0%), obesidade (32,0% para 37,0%) e índice de massa livre de gordura (17,9±2,5 para 17,5±3,5 kg/m2), índice de massa gorda aumentou (8,5±3,5 para 9,0±4,0 kg/m2), e obesidade sarcopênica (0 para 2,0%) também aumentaram, embora não significativamente. O gênero feminino foi associado à sarcopenia. Conclusão: Após a operação, a gordura aumentou ao longo dos anos e a massa magra diminuiu, embora não significativamente. A sarcopenia e a obesidade estavam presentes após o transplante; no entanto, a obesidade sarcopênica não foi realidade observada nesses pacientes.

PREVALENCE AND RISK FACTORS OF HYPERKALEMIA AFTER LIVER TRANSPLANTATION.

BACKGROUND: There is a lack of data regarding hyperkalemia after liver transplantation. AIM: To evaluate the prevalence of hyperkalemia after liver transplantation and its associated factors. METHODS: This retrospective cohort study evaluated 147 consecutive post-transplant patients who had at least one year of outpatient medical follow up. The data collection included gender, age, potassium values, urea, creatinine, sodium and medication use at 1, 6 and 12 months after. Hyperkalemia was defined as serum potassium concentrations higher than 5.5 mEq/l. RESULTS: Hiperkalemia was observed in 18.4%, 17.0% and 6.1% of patients 1, 6 and 12 months after tranplantation, respectively. Older age (p=0.021), low creatinine clearance (p=0.007), increased urea (p=0.010) and hypernatremia (p=0.014) were factors associated with hyperkalemia, as well as the dose of prednisone at six months (p=0.014). CONCLUSION: Hyperkalemia was prevalent in less than 20% of patients in the 1st month after liver transplantation and decreased over time. Considering that hyperkalemia does not affect all patients, attention should be paid to the routine potassium intake recommendations, and treatment should be individualized.

Combined nutritional assessment methods to predict clinical outcomes in patients on the waiting list for liver transplantation.

OBJECTIVES: Nutritional diagnosis is essential given that malnutrition negatively affects morbidity and mortality in patients with liver disease. In the absence of a standard method, limited accuracy has been reported in relation to nutritional assessment. The aim of the study was to evaluate the use of subjective global assessment (SGA) and different methods of nutritional assessment, isolated and in combination with SGA to predict clinical outcomes. METHODS: This was a longitudinal study with patients waiting for liver transplantation. Nutritional status was classified according to SGA. Anthropometric parameters, standard phase angle (SPA), handgrip strength, and 6-min walk test (6MWT) were evaluated. Univariate and multivariate analysis and receiver operator characteristic curve were performed. P < 0.05 was statistically significant. RESULTS: Seventy-three patients with an average age of 52.3 ± 11.4 y were evaluated. Of these, 63% were men. Low midarm muscle area (MAMA; P < 0.001), malnutrition by SGA + low MAMA (P < 0.001), and malnutrition by SGA + low SPA (P < 0.001) were independent predictors of clinical features of advanced cirrhosis. SGA + SPA presented the greater area under the curve (AUC: 0.6431). Death was predicted by low midarm circumference (MAC; P = 0.037) and slow gait speed on the 6MWT (GS-6MWT; P = 0.017), with both parameters isolated or concomitantly linked to malnutrition. SGA + GS-6MWT presented the highest predictive power for death (AUC: 0.6673) slightly greater than SGA+MAC (AUC: 0.6346). CONCLUSION: The results indicate that SGA together with SPA has greater predictive power for features of advanced cirrhosis, and SGA plus gait speed is able to better predict mortality in patients on the waiting list for liver transplant.

Prevalence and risk factors of hyperkalemia after liver transplantation / Prevalência e fatores de risco associados à hipercalemia após o transplante hepático

ABSTRACT Background: There is a lack of data regarding hyperkalemia after liver transplantation. Aim: To evaluate the prevalence of hyperkalemia after liver transplantation and its associated factors. Methods: This retrospective cohort study evaluated 147 consecutive post-transplant patients who had at least one year of outpatient medical follow up. The data collection included gender, age, potassium values, urea, creatinine, sodium and medication use at 1, 6 and 12 months after. Hyperkalemia was defined as serum potassium concentrations higher than 5.5 mEq/l. Results: Hiperkalemia was observed in 18.4%, 17.0% and 6.1% of patients 1, 6 and 12 months after tranplantation, respectively. Older age (p=0.021), low creatinine clearance (p=0.007), increased urea (p=0.010) and hypernatremia (p=0.014) were factors associated with hyperkalemia, as well as the dose of prednisone at six months (p=0.014). Conclusion: Hyperkalemia was prevalent in less than 20% of patients in the 1st month after liver transplantation and decreased over time. Considering that hyperkalemia does not affect all patients, attention should be paid to the routine potassium intake recommendations, and treatment should be individualized.

RESUMO Racional: Existe lacuna na literatura em relação à presença de hipercalemia em pacientes submetidos ao transplante hepático. Objetivo: Avaliar a prevalência de hipercalemia após o transplante hepático; e avaliar os fatores de risco associados a essa condição. Métodos: Estudo de coorte retrospectivo, no qual foram avaliados 147 pacientes submetidos ao transplante hepático, com tempo de seguimento de um ano. A coleta de dados compreendeu gênero, idade, valores séricos de potássio, ureia, creatinina, sódio e medicamentos utilizados no tempo de 1, 6 e 12 meses após o transplante. Hipercalemia foi definida como valores de potássio sérico maiores do que 5,5 mEq/l. Resultados: Hipercalemia foi observada em 18,4%, 17,0% e 6,1% dos pacientes no 1º, 6º e 12º meses após o transplante, consecutivamente. Idade avançada (p=0,021), baixos valores de creatinina sérica (p=0,007), valores aumentados de ureia (p=0,010) e hipernatremia (p=0,014) foram fatores associados à hipercalemia, assim como a dose de prednisona no 6º mês após o transplante (p=0,014). Conclusão: Hipercalemia esteve presente em menos de 20% dos pacientes no primeiro mês após o transplante hepático, com diminuição da prevalência ao longo do tempo. Considerando que ela não afeta todos os pacientes, o tratamento dietético deve ser individualizado, com especial atenção à recomendação de administração de potássio de forma rotineira.

Nutritional Status Parameters as Risk Factors for Mortality in Cancer Patients.

The aim of this study was to verify the relationship between weight loss, handgrip strength (HGS) and phase angle (PA) before the beginning of chemotherapy with overall survival in cancer patients. Patients diagnosed with gastrointestinal and breast cancer who were over 18 years old and were scheduled to undergo adjuvant treatment at Hospital Borges da Costa/Brazil were evaluated. The exclusion criteria were neoadjuvant treatment, patients with kidney and liver disease and using diuretics. Weight, HGS and PA tests were performed by trained dietitians. The Kaplan-Meier survival method and the log-rank test, cox regression and ROC curve were used and p < 0.05 was considered significant. Two-hundred and twenty-eight patients were evaluated.The median survival time was higher among the patients who showed weight loss of less than 10% of usual body weight (p < 0.05). Regarding HGS, patients with decreased HGS had a 22.0 month survival versus 34.2 months for those with normal values (p < 0.05). 146 patients had normal PA values, and these patients had increased survival time compared to those with inappropriate values (p < 0.05). In the Cox regression, weight loss and PA were predictors of mortality, HGS wasn't significantly associated with mortality. ROC analysis revealed that weight loss was the nutritional status parameter with the most predictive power.

Functional status and heart rate variability in end-stage liver disease patients: association with nutritional status.

OBJECTIVES: Muscle dysfunction and reduced heart rate variability (HRV) are common in patients with advanced liver disease, and both are related to poor outcomes. Malnutrition is also highly prevalent in these patients, however, the association between the malnutrition and HRV has not yet been assessed. The aim of this study was to evaluate the short-term HRV, functional and nutritional statuses in patients with advanced liver disease. METHODS: The nutritional and functional statuses were determined by subjective global assessment, handgrip strength (dynamometer, JAMAR) and gait speed during a 6-minute walk text (6MWT), respectively. The cardiac workload index (CWI) was used to evaluate the cardiac response to the 6MWT. The time domain (SD of all normal-to-normal intervals [SDNN]) and very-low, low-, and high-frequency domains of short-term HRV were evaluated with RS800 CX (Polar, Finland) and Cardioseries software (Brazil). RESULTS: The study evaluated 42 patients with liver disease (62% men) and malnutrition was found in 62% of this population. The malnourished participants presented with reduced functional status, 41% decreased SDNN, and 14% greater CWI compared with well-nourished individuals (P < 0.05). Additionally, the CWI was negatively associated to SDNN (r = 0.414; P < 0.05) and gait speed (r = 0.598; P < 0.05), especially in malnourished individuals (r = 0.650; P < 0.05). These data indicate that malnourished patients with liver disease have higher cardiovascular risk related to reduced functional status, which may be associated to poor outcomes during the course of the disease before and after transplant. Another relevant aspect is that the 6MWT associated to HRV could be a useful tool to screen liver disease patients who have a higher risk for cardiovascular complications.