Khan Saniya, Benjamin Jaya, Maiwall Rakhi, Tripathi Harshita, Kapoor Puja Bhatia, Shasthry Varsha, Saluja Vandana, Agrawal Prashant, Thapar Shalini, Kumar Guresh
Department of Clinical Nutrition, Institute of Liver and Biliary Sciences, New Delhi, India.
Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
J Clin Transl Res. 2022 May 25;8(3):200-208. eCollection 2022 Jun 29.
Sarcopenia is strongly associated with poor outcome in cirrhosis. There are little prospective data that sarcopenia influences outcomes in critically ill cirrhotics (CICs). Computed tomography (CT) is the gold standard for sarcopenia assessment in the intensive care unit (ICU), as it is independent of hydration status.
This study aims to assess the prevalence of sarcopenia and study its impact on clinical outcomes in CICs.
In this prospective observational study, CICs admitted to the liver ICU were enrolled, if meeting inclusion (age 18-70 years, abdominal CT scan within three months before ICU admission) and exclusion criteria (survival likely to be <24 h, coexisting chronic diseases). Clinical, hemodynamic, biochemical, and nutritional parameters, including length of stay (LOS), duration of mechanical ventilation (MV), development of new-onset infections (NOI), incidence of new-onset acute kidney injury (AKI), and overall survival, were recorded. CT images at the L3 level were analyzed using Slice-O-Matic V4.3 software to assess the skeletal muscle index (SMI) expressed as skeletal muscle area (cm)/height (m). Sarcopenia was defined if SMI was <50 cm/m - males and <39 cm/m - females. Data were analyzed using SPSS version 22.
Altogether 111 patients (M-83.8%; age 48.4±11.3 years; etiology: Alcohol - 56 [50.5%], non-alcoholic steatohepatitis - 27 [24.3%], viral - 12 [10.8%], and others - 16 [14.4%]; Child-Turcotte-Pugh - 11.9±1.8; model for end-stage liver disease - 27.8±7.3; sequential organ failure assessment - 10.5±4.1; APACHE - 23±8; and MV - 54 [48.6%]) were enrolled. Of these, 76 (68.5%) were sarcopenic and 35 (31.5%) non-sarcopenic. Sarcopenic CICs had higher overall mortality (72.4%) compared to non-sarcopenics (40%) (=0.001, OR [95% CI] - 3.93 [1.69-9.12]), and higher prevalence of sepsis at ICU admission (53.9% vs. 31.4%, =0.027, OR [95% CI] - 1.7 [1.0-2.92]) than non-sarcopenics. LOS, duration of MV, incidence of NOI, and development of new-onset AKI were comparable between groups. Multivariate binary logistic regression showed that sarcopenia, sepsis, and APACHE II score were independently associated with mortality.
Two-thirds of CICs have sarcopenia at ICU admission, making them 1.7 times more susceptible to sepsis and increasing the risk of mortality by almost 4-fold in the ICU.
Almost 70% of patients with chronic liver disease admitted to the ICU have low muscle mass (sarcopenia). The presence of sarcopenia per se makes them highly prone to infections and increases the chances of death by almost 4-fold; thus, highlighting the importance of nutrition optimization in this patient group.
肌肉减少症与肝硬化患者的不良预后密切相关。关于肌肉减少症对重症肝硬化患者（CICs）预后影响的前瞻性数据较少。计算机断层扫描（CT）是重症监护病房（ICU）中评估肌肉减少症的金标准，因为它不受水化状态的影响。
本研究旨在评估CICs中肌肉减少症的患病率，并研究其对临床结局的影响。
在这项前瞻性观察研究中，纳入入住肝脏ICU的CICs患者，需符合纳入标准（年龄18 - 70岁，ICU入院前三个月内进行腹部CT扫描）和排除标准（预计生存期<24小时，并存慢性疾病）。记录临床、血流动力学、生化和营养参数，包括住院时间（LOS）、机械通气时间（MV）、新发感染发生率（NOI）、新发急性肾损伤发生率（AKI）以及总体生存率。使用Slice - O - Matic V4.3软件分析L3水平的CT图像，以评估骨骼肌指数（SMI），其定义为骨骼肌面积（cm²）/身高（m）。男性SMI<50 cm²/m且女性SMI<39 cm²/m定义为肌肉减少症。使用SPSS 22版软件进行数据分析。
共纳入111例患者（男性占83.8%；年龄48.4±11.3岁；病因：酒精性 - 56例[50.5%]，非酒精性脂肪性肝炎 - 27例[24.3%]，病毒性 - 12例[10.8%]，其他 - 16例[14.4%]；Child - Turcotte - Pugh评分 - 11.9±1.8；终末期肝病模型评分 - 27.8±7.3；序贯器官衰竭评估评分 - 10.5±4.1；急性生理与慢性健康状况评分系统II - 23±8；机械通气患者 - 54例[48.6%]）。其中，76例（68.5%）为肌肉减少症患者，35例（31.5%）为非肌肉减少症患者。与非肌肉减少症患者相比，肌肉减少症CICs患者的总体死亡率更高（72.4%对40%，P = 0.001，比值比[95%置信区间] - 3.93[1.69 - 9.12]），且ICU入院时脓毒症患病率更高（53.9%对31.4%，P = 0.027，比值比[95%置信区间] - 1.7[1.0 - 2.92]）。两组间LOS、MV时间、NOI发生率和新发AKI发生率相当。多因素二元逻辑回归显示，肌肉减少症、脓毒症和急性生理与慢性健康状况评分系统II评分与死亡率独立相关。
三分之二的CICs患者在ICU入院时存在肌肉减少症，这使他们发生脓毒症的易感性增加1.7倍，且在ICU中的死亡风险增加近4倍。
入住ICU的慢性肝病患者中，近70%存在低肌肉量（肌肉减少症）。肌肉减少症本身使他们极易发生感染，死亡几率增加近4倍；因此，凸显了该患者群体营养优化的重要性。
