The confluence of 2 prognostic titans

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Apr 17, 2018 - the Korean Sarcopenic Obesity Study (KSOS). Diabetes Care. 2010;33:1497-1499. 22. Park SH, Park JH, Song PS, et al. Sarcopenic obesity as ...
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Received: 9 March 2018    Accepted: 17 April 2018 DOI: 10.1111/liv.13876

REVIEW ARTICLE

Sarcopenic obesity in cirrhosis—The confluence of 2 prognostic titans Tannaz Eslamparast1 | Aldo J. Montano-Loza1

 | Maitreyi Raman2 | 

Puneeta Tandon1 1 Department of Medicine, University of Alberta, Edmonton, AB, Canada 2 Department of Medicine, University of Calgary, Calgary, AB, Canada

Abstract Sarcopenia and obesity are 2 major health conditions with a growing prevalence in cirrhosis. The concordance of these 2 conditions, sarcopenic obesity, is associated

Correspondence Puneeta Tandon, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada. Email: [email protected]

with higher rates of mortality and impact on the metabolic profile and physical func-

Handling Editor: Frank Tacke

strategies are focused on increasing muscle mass and strength. The present review

tion than either condition alone. To date, there is little consensus surrounding the diagnostic criteria for sarcopenia, obesity or as a result, sarcopenic obesity in patients with cirrhosis. Cross-­sectional imaging, although the most accurate diagnostic technique, has practical limitations for routine use in clinical practice. Management provides an overview of the diagnosis, pathophysiology, prognostic implications and management strategies available for sarcopenic obesity in cirrhosis. We also discuss the associated condition myosteatosis, the pathological accumulation of fat in skeletal muscle. Much work needs to be done to advance both clinical care and research in this area. Future directions require consensus definitions for sarcopenia, obesity and sarcopenic obesity, an expansion of our understanding of the complex pathogenesis of the muscle-­liver-­adipose tissue axis in cirrhosis and evidence to support management recommendations for nutrition, exercise and pharmacological therapies. KEYWORDS

cirrhosis, muscle mass loss, myosteatosis, sarcopenic obesity

1 |  I NTRO D U C TI O N

In concert with the global obesity epidemic, obesity is also becoming increasingly prevalent in cirrhosis11,12 affecting an estimated

Sarcopenia is characterized by a progressive decline of skeletal muscle

33% of USA patients who receive a liver transplant.13 Obesity is as-

mass and strength. Thirty to seventy per cent of patients with cirrhosis

sociated with increased rates of clinical decompensation and discor-

have sarcopenia, the varied prevalence based on the cut-­offs and meth-

dant data regarding the degree of impact it has on peri-­operative

ods used to make the diagnosis, the severity of liver damage, patient

and post-­transplant morbidity and mortality. This discordance is at-

1

sex, age and ethnicity.

2–6

Despite this heterogeneity, sarcopenia has

demonstrated its rigour as a robust independent predictor of poor clinical outcomes in cirrhosis, including functional limitations, low quality of life, increased healthcare-­associated infections and mortality.

5,7–10

tributed in part to the lack of correction of weight for volume overload and to the obesity paradox.12,14–16 The co-­occurrence of these 2 prevalent conditions—low muscle mass and increased fat mass—is termed “sarcopenic obesity.”17,18 In

Abbreviations: ATP, adenosine triphosphate; BCAA, branched-chain amino acid; BIA, bioimpedance analysis; BMI, body mass index; CT, computed tomography; DEXA, dual-energy X-ray absorptiometry; ESPEN, European Society for Clinical Nutrition and Metabolism (Parenteral and Enteral Nutrition); EWGSOP, European Working Group on Sarcopenia in Older People; IR, insulin resistance; ISHEN, International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus; MA, muscle attenuation; MRS, magnetic resonance spectroscopy; NAFLD, non-alcoholic fatty liver disease; NASH, non-alcoholic steatohepatitis; OR, odds ratio; SMI, skeletal muscle index; VO2, volume of oxygen.

Liver International. 2018;1–12.

wileyonlinelibrary.com/journal/liv   © 2018 John Wiley & Sons A/S. |  1 Published by John Wiley & Sons Ltd

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ESLAMPARAST et al.

2      

the general population, sarcopenic obesity is associated with an increased risk of metabolic and cardiovascular disease (dyslipidaemia, hyperglycaemia, insulin resistance, hypertension), liver dysfunc-

Key points

tion, mobility disability, frailty, increased healthcare costs19–27 and

• Sarcopenic obesity refers to low muscle mass in the con-

a 24% increased risk for all-­cause mortality as compared to con-

text of obesity. It affects up to 35% of patients awaiting

trols.

24

Existing studies in cirrhosis are limited, but have reported a

liver transplantation.

sarcopenic obesity prevalence of 20% to 35% (Table 1), and an as-

• The combination of sarcopenia and obesity in cirrhosis is

sociation with increased mortality.7,28 In the largest study to date,

associated with higher morbidity and mortality than ei-

Montano-­Loza and colleagues7 showed that cirrhotic patients with

ther condition alone.

sarcopenic obesity or myosteatosis had a worse median survival

• The pathogenesis of sarcopenic obesity in cirrhosis is

(22 ± 3 months, P