Frailty in Nonalcoholic Fatty Liver Cirrhosis: A Comparison with Alcoholic Cirrhosis, Risk Patterns, and Impact on Prognosis.

Background: Physical frailty increases susceptibility to stressors and predicts adverse outcomes of cirrhosis. Data on disease course in different etiologies are scarce, so we aimed to compare the prevalence and risk factors of frailty and its impact on prognosis in nonalcoholic fatty liver (NAFLD) and alcoholic (ALD) cirrhosis. Patients and Methods. Cirrhosis registry RH7 operates since 2014 and includes hospitalized patients with decompensated cirrhosis, pre-LT evaluation, or curable hepatocellular carcinoma (HCC). From the RH7, we identified 280 ALD and 105 NAFLD patients with at least 6 months of follow-up. Results: Patients with NAFLD compared with ALD were older and had a higher proportion of females, higher body mass index (BMI) and mid-arm circumference (MAC), lower MELD score, CRP, and lower proportion of refractory ascites. The liver frailty index did not differ, and the prevalence of HCC was higher (17.1 vs. 6.8%, p=0.002). Age, sex, serum albumin, and C-reactive protein (CRP) were independent predictors of frailty. In NAFLD, frailty was also associated with BMI and MAC and in ALD, with the MELD score. The Cox model adjusted for age, sex, MELD, CRP, HCC, and LFI showed that NAFLD patients had higher all-cause mortality (HR = 1.88 95% CI 1.32-2.67, p < 0.001) and were more sensitive to the increase in LFI (HR = 1.51, 95% CI 1.05-2.2). Conclusion: Patients with NAFLD cirrhosis had a comparable prevalence of frailty compared to ALD. Although prognostic indices showed less advanced disease, NAFLD patients were more sensitive to frailty, which reflected their higher overall disease burden and led to higher all-cause mortality.

Adherence to Oral Nutritional Supplements After Being Discharged from the Hospital is Low but Improves Outcome in Patients with Advanced Chronic Liver Disease.

PURPOSE: Patients with advanced chronic liver disease (ACLD) often have a poor nutritional status. In the management, current guidelines recommend dietary counseling and oral nutritional supplements (ONS). Nutritional goals and adherence to ONS are difficult to achieve while studies addressing adherence are scarce. We aimed to evaluate adherence to ONS, the associated factors, and its impact on outcome among ALCD patients who are discharged from the hospital. PATIENTS AND METHODS: We identified consecutive hospitalized patients with ACLD from the cirrhosis registry and ONS prescription at discharge. Baseline demographics, anthropometrics, hand-grip strength (HGS), nutritional, and laboratory parameters were recorded. Adherence was assessed at 30, 90, and 180 days, but not in patients who did not survive or in those who underwent liver transplantation (LT) before the time-point. RESULTS: From the registry containing 1004 patients, we included 450 cases, the median age was 56.3 (IQR 47-62), 60% were males, 63.8% had alcoholic etiology, and the median model for end-stage liver disease score (MELD) was 16 (11-21). During follow-up, 13.6%, 23.6%, and 31.1% of patients have died within 30, 90, and 180 days, respectively, and 21 underwent LT. Adherence to ONS in surviving patients was observed in 46%, 26.1%, and 16.9% within 30, 90, and 180 days, respectively. Baseline refractory ascites (HR=0.43, 0.24-0.76), HGS (HR=1.03, 1.01-1.06), and mid-arm circumference (HR=0.93, 0.88-0.99) were independently associated with 30-day adherence. Among patients who survived beyond 30 days, adherents for >30 days had improved synthetic liver function, HGS, a higher probability of LT (HR=1.7, 1.03-2.8) and lower risk of death (HR=0.65, 0.45-0.89), particularly those with MELD>16 (OR=0.55, 0.36-0.85) and low HGS (OR=0.61, 0.39-0.93). CONCLUSION: In ACLD patients after discharge, adherence to ONS steeply declined and was associated with baseline refractory ascites and low muscle strength. Adherence to ONS also improved liver function, muscle strength, and survival.

[Acute decompensation (AD) of advanced chronic liver disease (ACLD) and hepatitis E virus (HEV) infection as the trigger].

INTRODUCTION: HEV infection is perceived as the cause of acute hepatitis in endemic areas. In addition, it may also manifest as a possible trigger of AD or acute-on-chronic liver failure (ACLF). OBJECTIVES: To determine the prevalence of HEV infection as a trigger of AD/ACLF in patients admitted for decompensated ACLD (dACLD). METHODS: A retrospective study; data analysis of consecutive patients with dACLD admitted to a liver unit. Study interval: August 2016 - October 2017. INCLUSION CRITERIA: AD, defined as the interval between the first manifestations of decompensation and admission ≤ 4 weeks; an anti-HEV ELISA antibody assay in the IgG and IgM classes (HEV Ab ELISA, DRG Instruments GmbH, Germany). EXCLUSION CRITERIA: chronic decompensation of liver cirrhosis, insufficient data. Recorded variables: gender, age, etiology of ACLD, Model for End-Stage Liver Disease (MELD) score, Child-Turcotte-Pugh score (CTPS), anti-HEV IgG and IgM, ACLF 0-3, length of stay (LOS) in the hospital, mortality: in-hospital mortality (IHM), 30-day, 6-month, 1-year and overall mortality. RESULTS: Over the 15-month study interval, a total of 212 patients (pts) were admitted for dACLD, including 115 with AD (54 %). The final analysis comprised 91 pts with a mean age of 53.3 years (y); 56 % were men. ETIOLOGY: ALD 81 %, autoimmune diseases 7 %, HCV 5 %, non-alcoholic steatohepatitis 3 %, HBV 2 %, others 2 %. The mean MELD score and CTPS were 22.5 and 10.5 points (p), respectively. HEV infection as a possible trigger of AD was found in 9 % of pts (AD 75 %, ACLF 1-12.5 %, ACLF 3-12.5 %). Between HEV-positive and HEV-negative patients, there were no significant differences in age (p = 0.11), gender (p = 0.13), median MELD score (p = 0.42), median CTPS (p = 0.57), LOS (p = 0.56), overall survival (p = NS), IHM (p = NS), 30-day (p = NS), 6-month (p = NS), 1-year (p = NS) and overall mortality (p = NS). CONCLUSION: The prevalence of HEV infection as a trigger of AD was 9 %. There were no significant differences in recorded variables, including mortality, between HEV-negative and HEV-positive patients.