Study On The Role Of Skeletal Muscle Malnutrition In Clinical Prognosis Prediction For Cirrhotic Patients

Background:Sarcopenia and Myosteatosis resulting from malnutrition are common complications in patients with cirrhosis,the main clinical manifestations including decreased skeletal muscle mass,weakened strength and impaired function.The third lumbar skeletal muscle index(L3 Skeletal muscle index,L3 SMI)and skeletal muscle density(SMD)are important indicators of skeletal muscle mass and function.Though there are already some studies aimed to investigate the effect of muscle malnutrition on the prognosis of cirrhosis,most of them are single-center studies,the sample size is relatively small.Importantly,all of the previous studies just focused on the mass of skeletal muscle instead of determining the effect of the skeletal density as well as the mass.To date,researches on the role of skeletal muscle malnutrition and on the prognosis of Chinese cirrhotic patients is still lacking.Aim:To explore the role of sarcopenia and myosteatosis in the prevalence and prognostic of cirrhotic patients.Methods:Our study retrospectively enrolled 480 patients with cirrhosis from Shanghai changzheng hospital,Tongji university oriental hospital and Shandong provincial hospital from Dec.31,2012 to Dec.31,2017,who were followed up by outpatient,inpatient and telephone once a year for a total of 2 years.We collected and record the relevant tests(Blood routine,liver and kidney function,etc.),general characteristics(such as age,gender,weight,etc.),and clinical data(such as etiology,complications,child-pugh score,etc.)after the enrollment.The image system was used to obtain the plain CT images of the upper abdomen of the patients during the enrollment.Based on the previous studies,CT value ranged from-29 to 150 hounsfield unit(HU)was used to identify the muscle in CT scan image.Then the skeletal muscle in third lumbar vertebra was marked and outlined,meanwhile,L3 SMI was obtained with an automatic map recognition software.Two separate samples t test was determined to compared the differences of indexes between patients with or without skeletal malnutrition.Spearman correlation analysis and univariate,multifactorial linear regression analysis were carried out to obtain the related factors of sarcopenia and myosteatosis.The Kaplan-meier survival curve was used to compare the difference of mortality between patients with or without skeletal malnutrition.A cox proportional risk regression model was used to analyze death-related independent risk factors in cirrhotic patients.Results:Diagnostic criteria for sarcopenia and myosteatosis in Chinese population based on previous studies involving 1396 normal Chinese(Sarcopenia: male L3 SMI <43.21 cm2/m2,female L3 SMI <31.96 cm2/m2;Myosteatosis: male L3 SMD < 36.90 HU,female L3 SMD <29.75HU).Among the cirrhotic individuals,88 cases(18.3%)were diagnosed with sarcopenia and 108 cases(22.5%)were diagnosed with myoteatosis.Compared with those cirrhotic patients without sarcopenia,patients with sarcopenia had lower BMI and hemoglobin,higher Child-Pugh score and MELD score,worse liver function,and more tendency to manifested ascites and SBP(P<0.05).In addition,compared with those cirrhotic patients without myosteatosis,patients with myosteatosis were older,and had higher BMI,higher Child-Pugh score and MELD score,worse liver function,and more tendency to experience episode of ascites,hepatic encephalopathy,spontaneous bacterial peritonitis,and hepatorenal syndrome(P < 0.05).By means of multiple linear regression,it was found that the L3 SMI was significantly correlated with ascites,spontaneous bacterial peritonitis and alanine transaminase.There was a significant correlation between L3 SMD and upper gastrointestinal bleeding,hepatorenal syndrome,Child-pugh score,serum direct bilirubin,and albumin.A 2-year follow-up revealed that the mortality of the patients with sarcopenia was 30.68%,while that in those patients without sarcopenia was 11.22%(P<0.001),patients with and without myosteatosis had 30.56% and 10.22% mortality(P<0.001).A COX proportional risk model analysis revealed that sarcopenia is an independent risk factor for death in patients with cirrhosis,with the RR 2.177,P=0.013.A COX proportional risk model analysis revealed that sarcopenia is an independent risk factor for complications in patients with cirrhosis,with the RR 1.476,P=0.021.The incidence of ascites,hepatic encephalopathy,spontaneous bacterial peritonitis and upper gastrointestinal bleeding during follow-up in patients with sarcopenia was obviously higher than that in those without sarcopenia(P<0.05).The incidence of ascites,hepatic encephalopathy,spontaneous bacterial peritonitis,upper gastrointestinal bleeding and hepatorenal syndrome in patients with myosteatosis was significantly higher than that in those without myosteatosis(P<0.05).Conclusion:Sarcopenia and myosteatosis are both common complications in patients with cirrhosis,and the morbidity and mortality of patients with skeletal muscle malnutrition are significantly increased in cirrhotic population.Sarcopenia is an independent risk factor for death and complications in patients with cirrhosis.Myosteatosis is associated with the occurrence of primary liver cancer in cirrhotic patients.