Correspondence on Letter regarding “Impacts of muscle mass dynamics on prognosis of outpatients with cirrhosis”

Article information

Clin Mol Hepatol. 2023;29(1):173-175
Publication date (electronic) : 2022 November 15
doi : https://doi.org/10.3350/cmh.2022.0372
Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
Corresponding author : Young Kul Jung Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan 15355, Korea Tel: +82-31-412-7670, Fax: +82-31-412-5582, E-mail: 93cool@hanmail.net
Editor: Seung Up Kim, Yonsei University College of Medicine, Korea
Received 2022 November 5; Revised 2022 November 9; Accepted 2022 November 10.

Dear Editor,

We sincerely appreciate the letter from Song et al. [1] for contemplating our recent paper on the prognostic impact of muscle mass change in outpatients with cirrhosis, published in Clinical and Molecular Hepatology [2]. We agree that sex and lifestyle influence muscle mass and that myosteatosis is an important prognostic marker in patients with cirrhosis.

Many diagnostic criteria for sarcopenia have been established based on sex-specific differences, and this study was conducted by adopting one of them. However, the change in muscle mass may differ from the muscle mass itself. In our study, change in muscle mass (ΔSMI)/yr%, which represented the change in muscle mass, was not an absolute value but a rate value divided by the muscle mass at inclusion. Thus, regardless of sex, the impact of ΔSMI/yr% could be consistent.

The analysis of subgroup according to sex, which was not presented in the original paper, revealed that ΔSMI/yr% continued to be an independent predictor for the development of cirrhosis complications in men even after adjusting for the model for end-stage liver disease score. In the case of women, the correlation marginally significant (Table 1), which might be attributed to the fact that women in our cohort were fewer and had a lower incidence of cirrhosis complications than men. In addition, every 1-point increase in ΔSMI/yr% was associated with a 5.4% and 4.0% reduction in the risk of cirrhosis complications in men and women, respectively.

Multivariable cox-regression analyses for the development of LC complication after 1-year CT according to sex

Of course, there were other results suggesting sex-specific differences such as cut-offs for the development of cirrhosis complications within 6 months (-5.74 and -2.62 in men and women, respectively).

Continuous alcohol consumption is an obvious aggravating factor for muscle loss, decompensation, and mortality in patients with alcohol-related liver disease [3-6]. In addition, abstinence is a fundamental treatment with long-term benefits, including a 10–30% reduction in mortality [4,7,8]. Thus, drinking behavior after inclusion could be an important factor in the prognosis of patients with cirrhosis, as mentioned by Song et al. [1]. However, drinking behavior is highly variable, and there is no standardized method for measuring it, making it difficult to incorporate into research [9]. Malnutrition and insufficient physical activity are well-known risk factors for sarcopenia and the prognosis of patients with cirrhosis. Conversely, a well-controlled diet and regular exercise could improve sarcopenia even in patients with cirrhosis [3,10-12].

Several pioneering studies have shown that myosteatosis is significantly associated with decompensation, hepatocellular carcinoma development, and mortality in patients with chronic liver disease [13-15]. Even in these studies, it was unclear whether myosteatosis was a better prognostic predictor than sarcopenia. However, it appeared to be a prognostic predictor acting independently of sarcopenia [15].

Myosteatosis and lifestyle, including drinking behavior, nutrition, and physical activity, are now considered essential in sarcopenia-related studies. However, as mentioned in the limitations of the original paper, the protocol in our cohort did not include measurements for these factors. Therefore, further studies are required to address these factors.

Notes

Authors’ contribution

Concept of the work: Y.K.J. and H.J.Y.; drafting article: T.H.K.; critical revision of the article: Y.K.J.

Conflicts of Interest

The authors have no conflicts to disclose.

Acknowledgements

We would like to thank Editage (www.editage.co.kr) for English language editing.

Abbreviations

ΔSMI

change in muscle mass

References

1. Song DS, Chang UI, Yang JM. Sarcopenia: multiple factors need to be considered in cirrhosis. Clin Mol Hepatol 2023;29:165–167.
2. Kim TH, Jung YK, Yim HJ, Baik JW, Yim SY, Lee YS, et al. Impacts of muscle mass dynamics on prognosis of outpatients with cirrhosis. Clin Mol Hepatol 2022;28:876–889.
3. Jindal A, Jagdish RK. Sarcopenia: ammonia metabolism and hepatic encephalopathy. Clin Mol Hepatol 2019;25:270–279.
4. Lackner C, Spindelboeck W, Haybaeck J, Douschan P, Rainer F, Terracciano L, et al. Histological parameters and alcohol abstinence determine long-term prognosis in patients with alcoholic liver disease. J Hepatol 2017;66:610–618.
5. Lesmana CRA, Raharjo M, Gani RA. Managing liver cirrhotic complications: overview of esophageal and gastric varices. Clin Mol Hepatol 2020;26:444–460.
6. Korean Association for the Study of the Liver (KASL). KASL clinical practice guidelines for liver cirrhosis: varices, hepatic encephalopathy, and related complications. Clin Mol Hepatol 2020;26:83–127.
7. Mann RE, Smart RG, Govoni R. The epidemiology of alcoholic liver disease. Alcohol Res Health 2003;27:209–219.
8. Pessione F, Ramond MJ, Peters L, Pham BN, Batel P, Rueff B, et al. Five-year survival predictive factors in patients with excessive alcohol intake and cirrhosis. Effect of alcoholic hepatitis, smoking and abstinence. Liver Int 2003;23:45–53.
9. Kim J, Kang W, Sinn DH, Gwak GY, Paik YH, Choi MS, et al. Substantial risk of recurrence even after 5 recurrence-free years in early-stage hepatocellular carcinoma patients. Clin Mol Hepatol 2020;26:516–528.
10. Bunchorntavakul C, Reddy KR. Review article: malnutrition/sarcopenia and frailty in patients with cirrhosis. Aliment Pharmacol Ther 2020;51:64–77.
11. Wang S, Whitlock R, Xu C, Taneja S, Singh S, Abraldes JG, et al. Frailty is associated with increased risk of cirrhosis disease progression and death. Hepatology 2022;75:600–609.
12. Aamann L, Dam G, Borre M, Drljevic-Nielsen A, Overgaard K, Andersen H, et al. Resistance training increases muscle strength and muscle size in patients with liver cirrhosis. Clin Gastroenterol Hepatol 2020;18:1179–1187. e6.
13. Nardelli S, Lattanzi B, Merli M, Farcomeni A, Gioia S, Ridola L, et al. Muscle alterations are associated with minimal and overt hepatic encephalopathy in patients with liver cirrhosis. Hepatology 2019;70:1704–1713.
14. Tachi Y, Kozuka A, Hirai T, Ishizu Y, Honda T, Kuzuya T, et al. Impact of myosteatosis on skeletal muscle volume loss in patients with chronic liver disease. J Gastroenterol Hepatol 2018;33:1659–1666.
15. Lattanzi B, Nardelli S, Pigliacelli A, Di Cola S, Farcomeni A, D’Ambrosio D, et al. The additive value of sarcopenia, myosteatosis and hepatic encephalopathy in the predictivity of model for end-stage liver disease. Dig Liver Dis 2019;51:1508–1512.

Article information Continued

Table 1.

Multivariable cox-regression analyses for the development of LC complication after 1-year CT according to sex

HR 95% CI P-value
ΔSMI/yr%
Men (n=381) 0.946 0.917–0.976 <0.001
Women (n=214) 0.960 0.921–1.001 0.055

Results were derived after adjusting for age and model for endstage liver disease score.

LC, liver cirrhosis; CT, computed tomography; HR, hazard ratio; CI, confidence interval; ΔSMI, change in muscle mass.