Montano-Loza A J
Division of Gastroenterology and Liver Unit University of Alberta HospitalEdmonton, Alberta, Canada -
Minerva Gastroenterol Dietol. 2013 Jun;59(2):173-86.
The natural history of cirrhotic patients is highly variable due to several factors including hepatic synthetic function, presence and degree of portal hypertension, the cause of cirrhosis, the possibility of resolution of the underlying damaging process, and the occurrence of liver cancer. Currently, D'Amico stage classification and Child-Pugh and Model for End-Stage Liver Disease (MELD) scores constitute the best tools to predict mortality in patients with cirrhosis; however, one of their main limitations is the lack of evaluation of the nutritional and functional status. Most widely recognized complications in cirrhotic patients include ascites, hepatic encephalopathy, variceal bleeding, kidney dysfunction, and hepatocellular carcinoma; however, sarcopenia or severe muscle wasting is one of the most common and frequently hidden complications which negatively impact survival, quality of life, and response to stressor, such as infection and surgery. In this review, we discuss the current accepted and new methods to evaluate prognosis in cirrhosis, and also analyze the current knowledge regarding incidence and clinical impact of malnutrition and sarcopenia in cirrhosis and their impact after liver transplantation. We also discuss existing and potential novel therapeutic strategies for malnutrition in cirrhosis, emphasizing the recognition of sarcopenia in cirrhosis in an effort to improve survival and reduced morbidity related to cirrhosis. Finally, we propose that future studies including sarcopenia with the MELD score may allow better prediction of mortality among cirrhotic patients waiting for liver transplantation; however, due to the worldwide shortage of organs for transplants, one of the vital clinical questions is the feasibility to treat sarcopenia in cirrhosis without the need of liver transplant.
肝硬化患者的自然病程因多种因素而高度可变，这些因素包括肝脏合成功能、门静脉高压的存在及程度、肝硬化的病因、潜在损伤过程缓解的可能性以及肝癌的发生。目前，达米科分期分类、Child-Pugh评分和终末期肝病模型（MELD）评分是预测肝硬化患者死亡率的最佳工具；然而，它们的主要局限性之一是缺乏对营养和功能状态的评估。肝硬化患者最广为人知的并发症包括腹水、肝性脑病、静脉曲张出血、肾功能障碍和肝细胞癌；然而，肌肉减少症或严重肌肉萎缩是最常见且常常被忽视的并发症之一，会对生存、生活质量以及对感染和手术等应激源的反应产生负面影响。在本综述中，我们讨论了目前公认的和新的评估肝硬化预后的方法，还分析了关于肝硬化中营养不良和肌肉减少症的发生率及其临床影响以及肝移植后影响的现有知识。我们还讨论了肝硬化中营养不良的现有及潜在新治疗策略，强调对肝硬化中肌肉减少症的认识，以努力提高生存率并降低与肝硬化相关的发病率。最后，我们提出，未来将肌肉减少症纳入MELD评分的研究可能会更好地预测等待肝移植的肝硬化患者的死亡率；然而，由于全球范围内器官移植短缺，一个重要的临床问题是在不进行肝移植的情况下治疗肝硬化中肌肉减少症的可行性。
