Impact of liver function on muscle mass estimation in liver cirrhosis: Anthropometriy and the...
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Al148 AASLD ABSTRACTS GASTROENTEROLOGY, Vol. 108, No. 4 • INTERLEUKIN 6 AND TNF LEVELS IN SERUM AND ASCITIC FLUID OF CIRRHOTIC PATIENTS WITH ASCITES AND SPONTANEOUS BACTERIAL PERITONITIS. H:Cortez pintp,A.J.Pedro,P.Alexandrino, F.Ra- malho,M.Carneiro de Moura.Dept.Med.2,Liver Unit,Santa Ma- ria Hospital,Lisbon,Portugal. Elevated levels of tumor necrosis factor alpha (TNF#) and interleukin 6 (IL6) have been reported in infected cirrho- tic patients. High levels of IL6 have also been found in ascitic fluid of patients with malignant ascites and cirr- hotic patients, with higher levels in spontaneous bacte- rial peritonitis (SBP). In order to evaluate the relation- ship between TNF and IL6 levels in serum and ascitic fluid, in infected and non infected patients, we studied 79 cirr- hotic patients admitted with ascites. Mean age was 56 years, 74 males and 5 females. Serum and ascitic fluid levels of TNF~ and IL6 were measured by an enzyme immunoassay (ELI- SA), at admission (Table). SBP was defined as polymorphon~ clear (PMN) cell count > 250/mm3 or positive ascitic fluid culture. 25 cases of SBP were found. With SBP Without SBP p = Serum TNF (pg/ml) 36.8+22.3 12.6~4.9 ns Ascitic fluid TNF(pg/ml) 42 T28.5 0 0.Of Serum IL6 (pg/ml) 510 T263 123 +62.1 0.0007 Ascitic fluid IL6(pg/ml) 1770~317 856~88 0.0003 High levels of IL6 were found in serum and ascitic fluid, in most patients. However levels of IL6 were significantly higher in ascitic fluid than in serum. Moreover either in ascitic fluid or in serum they were significantly higher in patients with SBP. TNF levels in ascitic fluid were al- so higher in SBP patients, but with a lower significance level. Our results suggest that IL6 is probably produced in the peritoneal cavity, and when ascites is infected there are probably immunological factors that lead to oyez production of cytokines, what could be responsabile for the systemic manifestations usually seen in this situation. ACTIGRAPHY : A NEW METHOD IN THE CONTINUOUS ASSESSMENT OF HEPATIC ENCEPHALOPATHY. M.A. Piquet, J.P.Toudic, P. Denise*, A Peytier, P. Bustany**, J.C.Verwaerde, T. Dam Dpts of Hepatogastroenterology, Neurophysiology* and Pharmacology**. CHU 14033 Caen cedex FRANCE. Actigraphy is a method of wrist motor activity monitoring particularly fitted to the rhythms rest-activity study. The actemeter is a case fastened to the wrist like a watch. The aim of our study was to assess prospectively actigraphy in hepatic encephalopathy. Patients and methods: Motor activity was recorded continuously for 3 days with an actigraphic system in 25 hospitalized cirrhotic patients, with (n=12) and without (n=13) hepatic encephalopathy. The actigraphic judgement criteria were the average score of activity and inactivity. Actigraphy was compared to clinical assessment, trailmaking and number connection tests,visual evoked potentials (VEP) and electroencephalography (EEG). Results: There was no significant correlation between the clinical grades of encephalopathy and VEP (latencies of waves N2, P2, N3) or trailmaking test. On the other hand, clinical grades were significantly correlated with number connection test (r=0.81; p<0.0001) and mean dominant frequency of the EEG (r---0.65; p--0.003). There was a significant correlation between the clinical grades of encephalopathy and the average score of acfigraphic inactivity (r=0.55; p=0.005) and activity (r=0.7 ; p<0.0001; this correlation was better than the one achieved with EEG). The patients with moderate encephalopathy (grades1 and 2) versus patients without encephalopathy were deafly classified using the average score of activity (5.33 ms _+ 1.6 vs 3.28 mn -+1.4; p = 0.016). In the same way, there was a significant correlation between the average score of activity and mean dominant frequency of the EEG (r=0.62; p = 0.004). Conclusion: Actigraphy is a simple and objective method in the assessment of hepatic encephalopathy, particularly efficient in low grade encephalopathy. Contrary to conventional methods, actigraphy allows a continuous assessment of encephalopathy applicable to outpatients. • IMPACT OF LIVER FUNCTION ON MUSCLE MASS ESTIMATION IN L I V E R CIRRHOSIS: ANTHROPOMETRIY AND THE CREATININE METHOD. M.Pirlich I, M.J.ME)ller 2, M.Schwarze 2, E.Kirchner 1, M.P.Manns2, O.Selberg 3. Depts. of Anaesthesiology ~, Gastroenterology and Hepatology 2 & Clinical Chemistry 3, Medizinische Hochschule Hannover, Germany. The validity of the creatinine approach to estimate muscle mass in patients with liver cirrhosis is uncertain, because creatine is synthesized in the liver [Hepatology 1990;11:502]. Thus, reduced liver function may partly explain the low levels of urinary creatinine excretion frequently observed in these patients. Therefore, we investigated 102 patients with histologically proven liver cirrhosis (age: 44 + 12 years; sex: 52 f, 50 m; BMI: 23.4 + 4 kg/m ~) of different clinical state (Child-Pugh score: A n=19, B n= 48, C n=35). Muscle mass was assessed by 24-hr urinary creatinine excretion (MMC) (lg creatinine = 18.5 kg muscle mass) and from anthropometric data (MMA) according to Heymsfield (muscle mass = height * [0.0264 + 0.0029 * arm muscle area]; Am J Clin Nutr 1982; 36:680). Cholinesterase, albumin, iron-binding capacity, prothrombin time, bilirubin, methionine, ammonia and the results of quantitative liver function tests (indocyanine green: 0.5 mg/kg body weight; caffeine: 3 mg/kg body weight; and lignocaine: 1 mg/kg body weight) were taken as parameters of liver function. In addition we measured total body potassium in a subgroup of patients (n=26) for the calculation of body cell mass (BCM). MMC correlated significantly with MMA (r=0.49, p<O.O01) and BCM (r=0.71 p<O.O01). However, MMC was significantly higher than MMA (23.9 + 10.4 kg vs. 20.7 _+ 6.1 kg, p<O.O01). Moreover, the differences between MMA and MMC showed no correlation with the Child score, the b~ochemical parameters of liver function and the results of quantitative liver function tests. We conclude that reduced liver function in patients with liver cirrhosis does not systematically affect the urinary creatinine method for estimation of the muscle mass. Supported by the B.Braun Stiftung Me]sungen, Germany. LACK OF CHILD-PUGH SCORE TO DETECT POOR NUTRITIONAL AND METABOLIC STATE IN PATIENTS WITH LIVER CIRRHOSIS. M.Pirlich I, M.J.ML)ller~, E.Kirchner I, M.P.Manns2, O.Selberg 3, Depts. of Anaesthesiology~, Gastroenterology and Hepatology 2 & Clinical Chemistry 3, Medizinische Hochschule Hannover, Germany. \ The Child-Pugh score is an established prognostic parameter in patients with liver cirrhosis. However, hypermetabo]ism and malnutrition also contribute to the outcome of these patients [Hepatology 1992; 15:782-794]. We therefore investigated 108 patients with biopsy- proven liver cirrhosis (age: 44 + 13 years; sex: 55 f, 53 m; BMI: 23.4 + 4 kg/m z) of different clinical state (Child-Pugh score: A n=21, B n=49, C n=38). Nutritional state was assessed by anthropometry for estimation of the muscle mass and bioelectrical impedance analysis (BIA 101, R.IL Systems, Detroit, MI) for calculation of the body cell mass (BCM). Resting energy expenditure (REE) was assessed by indirect calorimetry (Deltatrac Metabolic Monitor, Datex Instr., Finland). In addition, we performed oral glucose tolerance tests and quantitative liver function tests (LFT) (indocyanine green [ICG], caffeine and lignocaine). 19% of our patients were hypermetabolic (REE > 120% of Harris Benedict prediction), 48% had respiratory quotients < 0.75, indicating increased lipid oxidation. 25% had reduced BCM (<30% of body weight), 13% diminished BMI (<19kg/m s) and 25% had reduced muscle mass (<20% of body weight). 36% had impaired glucose tolerance, 37% were diabetic. Child-Pugh score did not correlate with any nutritional or metabolic parameters, but showed close correlations to the results of the LFT (e.g.: ICG-t~. vs. Child: r=0.56, p<O.O01). Factor analysis showed that parameters of liver function (Child score, LFT), parameters of nutrition (BCM, BMI, muscle mass, urinary creatinine excretion) as well as metabolic parameters (REE, fuel mix, glucose tolerance)~were found in different factors with high factor loadings >/0.5. We conclude that the Child-Pugh score does not ~etect poor nutritional and metabolic status in patients with liver cirrhosis and should be extended accordingly. Supported by the B. Braun Stiftung Melsungen, Germany.
Transcript of Impact of liver function on muscle mass estimation in liver cirrhosis: Anthropometriy and the...
Al148 AASLD ABSTRACTS GASTROENTEROLOGY, Vol. 108, No. 4
• INTERLEUKIN 6 AND TNF LEVELS IN SERUM AND ASCITIC FLUID OF CIRRHOTIC PATIENTS WITH ASCITES AND SPONTANEOUS BACTERIAL PERITONITIS. H:Cortez pintp,A.J.Pedro,P.Alexandrino, F.Ra- malho,M.Carneiro de Moura.Dept.Med.2,Liver Unit,Santa Ma- ria Hospital,Lisbon,Portugal.
Elevated levels of tumor necrosis factor alpha (TNF#) and interleukin 6 (IL6) have been reported in infected cirrho- t i c patients. High levels of IL6 have also been found i n ascitic f luid of patients with malignant ascites and c i r r - hotic patients, with higher levels in spontaneous bacte- r ial peritonit is (SBP). In order to evaluate the relation- ship between TNF and IL6 levels in serum and ascit ic f lu id, in infected and non infected patients, we studied 79 c i r r - hotic patients admitted with ascites. Mean age was 56 years, 74 males and 5 females. Serum and ascitic f luid levels of TNF~ and IL6 were measured by an enzyme immunoassay (ELI- SA), at admission (Table). SBP was defined as polymorphon~ clear (PMN) cell count > 250/mm3 or positive ascit ic f luid culture. 25 cases of SBP were found.
With SBP Without SBP p = Serum TNF (pg/ml) 36.8+22.3 12.6~4.9 ns Ascitic f luid TNF(pg/ml) 42 T28.5 0 0.Of Serum IL6 (pg/ml) 510 T263 123 +62.1 0.0007 Ascitic f lu id IL6(pg/ml) 1770~317 856~88 0.0003
High levels of IL6 were found in serum and ascit ic f lu id, in most patients. However levels of IL6 were signif icantly higher in ascitic f luid than in serum. Moreover either in ascitic f lu id or in serum they were signif icantly higher in patients with SBP. TNF levels in ascitic f luid were al- so higher in SBP patients, but with a lower significance level. Our results suggest that IL6 is probably produced in the peritoneal cavity, and when ascites is infected there are probably immunological factors that lead to oyez production of cytokines, what could be responsabile for the systemic manifestations usually seen in this situation.
ACTIGRAPHY : A NEW METHOD IN THE CONTINUOUS ASSESSMENT OF HEPATIC ENCEPHALOPATHY. M.A. Piquet, J.P.Toudic, P. Denise*, A Peytier, P. Bustany**, J.C.Verwaerde, T. Dam Dpts of Hepatogastroenterology, Neurophysiology* and Pharmacology**. CHU 14033 Caen cedex FRANCE.
Actigraphy is a method of wrist motor activity monitoring particularly fitted to the rhythms rest-activity study. The actemeter is a case fastened to the wrist like a watch. The aim of our study was to assess prospectively actigraphy in hepatic encephalopathy. Patients and methods: Motor activity was recorded continuously for 3 days with an actigraphic system in 25 hospitalized cirrhotic patients, with (n=12) and without (n=13) hepatic encephalopathy. The actigraphic judgement criteria were the average score of activity and inactivity. Actigraphy was compared to clinical assessment, trailmaking and number connection tests,visual evoked potentials (VEP) and electroencephalography (EEG). Results: There was no significant correlation between the clinical grades of encephalopathy and VEP (latencies of waves N2, P2, N3) or trailmaking test. On the other hand, clinical grades were significantly correlated with number connection test (r=0.81; p<0.0001) and mean dominant frequency of the EEG (r---0.65; p--0.003). There was a significant correlation between the clinical grades of encephalopathy and the average score of acfigraphic inactivity (r=0.55; p=0.005) and activity (r=0.7 ; p<0.0001; this correlation was better than the one achieved with EEG). The patients with moderate encephalopathy (grades1 and 2) versus patients without encephalopathy were deafly classified using the average score of activity (5.33 ms _+ 1.6 vs 3.28 mn -+1.4; p = 0.016). In the same way, there was a significant correlation between the average score of activity and mean dominant frequency of the EEG (r=0.62; p = 0.004). Conclusion: Actigraphy is a simple and objective method in the assessment of hepatic encephalopathy, particularly efficient in low grade encephalopathy. Contrary to conventional methods, actigraphy allows a continuous assessment of encephalopathy applicable to outpatients.
• IMPACT OF LIVER FUNCTION ON MUSCLE MASS ESTIMATION IN L IVER CIRRHOSIS: ANTHROPOMETRIY AND THE CREATININE METHOD. M.Pirlich I, M.J.ME)ller 2, M.Schwarze 2, E.Kirchner 1, M.P.Manns 2, O.Selberg 3. Depts. of Anaesthesiology ~, Gastroenterology and Hepatology 2 & Clinical Chemistry 3, Medizinische Hochschule Hannover, Germany.
The va l id i ty of the creat in ine approach to estimate muscle mass in patients with l i ve r c i r rhosis is uncertain, because creat ine is synthesized in the l i ve r [Hepatology 1990;11:502]. Thus, reduced l i ve r funct ion may par t ly explain the low levels of u r i na ry creat in ine excret ion f requen t l y observed in these patients.
Therefore, we invest igated 102 patients wi th histological ly proven l i ve r c i r rhosis (age: 44 + 12 years; sex: 52 f, 50 m; BMI: 23.4 + 4 kg/m ~) of d i f f e ren t clinical state (Chi ld-Pugh score: A n=19, B n= 48, C n=35). Muscle mass was assessed by 24-hr u r i na ry creat in ine excret ion (MMC) ( lg creat in ine = 18.5 kg muscle mass) and from anthropometr ic data (MMA) according to Heymsfield (muscle mass = height * [0.0264 + 0.0029 * arm muscle area]; Am J Clin Nutr 1982; 36:680). Cholinesterase, albumin, i ron -b ind ing capacity, prothrombin time, b i l i rubin, methionine, ammonia and the results of quant i ta t ive l i ve r funct ion tests ( indocyanine green: 0.5 mg/kg body weight; caffeine: 3 mg/kg body weight; and l ignocaine: 1 mg/kg body weight) were taken as parameters of l i ve r funct ion. In addit ion we measured total body potassium in a subgroup of pat ients (n=26) fo r the calculation of body cell mass (BCM).
MMC correlated s ign i f i cant ly with MMA (r=0.49, p<O.O01) and BCM (r=0.71 p<O.O01). However, MMC was s ign i f icant ly h igher than MMA (23.9 + 10.4 kg vs. 20.7 _+ 6.1 kg, p<O.O01). Moreover, the di f ferences between MMA and MMC showed no correlat ion with the Child score, the b~ochemical parameters of l i ve r funct ion and the results of quant i ta t ive l i ve r funct ion tests.
We conclude tha t reduced l i ve r funct ion in pat ients with l i ve r c i r rhosis does not systematical ly af fect the u r i na ry creat in ine method fo r estimation of the muscle mass.
Supported by the B.Braun St i f tung Me]sungen, Germany.
LACK OF CHILD-PUGH SCORE TO DETECT POOR NUTRITIONAL AND METABOLIC STATE IN PATIENTS WITH LIVER CIRRHOSIS. M.Pirlich I, M.J.ML)ller~, E.Kirchner I, M.P.Manns 2, O.Selberg 3, Depts. of Anaesthesiology~, Gastroenterology and Hepatology 2 & Clinical Chemistry 3, Medizinische Hochschule Hannover, Germany.
\ The Chi ld-Pugh score is an established prognost ic
parameter in patients with l i ve r c irrhosis. However, hypermetabo]ism and malnutr i t ion also cont r ibu te to the outcome of these patients [Hepatology 1992; 15:782-794].
We therefore invest igated 108 patients with b iopsy- proven l i ve r c i r rhosis (age: 44 + 13 years; sex: 55 f, 53 m; BMI: 23.4 + 4 kg/m z) of d i f fe ren t clinical state (Chi ld-Pugh score: A n=21, B n=49, C n=38). Nutr i t ional state was assessed by anthropometry for estimation of the muscle mass and bioelectrical impedance analysis (BIA 101, R.IL Systems, Detroit, MI) fo r calculation of the body cell mass (BCM). Resting energy expendi ture (REE) was assessed by ind i rec t calor imetry (Deltatrac Metabolic Monitor, Datex Inst r . , Finland). In addit ion, we performed oral glucose tolerance tests and quant i ta t ive l i ve r funct ion tests (LFT) ( indocyanine green [ICG], caffeine and l ignocaine).
19% of our pat ients were hypermetabol ic (REE > 120% of Harris Benedict predict ion), 48% had resp i ra tory quot ients < 0.75, indicat ing increased l ipid oxidation. 25% had reduced BCM (<30% of body weight), 13% diminished BMI (<19kg/m s) and 25% had reduced muscle mass (<20% of body weight). 36% had impaired glucose tolerance, 37% were diabetic. Chi ld-Pugh score did not correlate with any nutr i t ional or metabolic parameters, but showed close correlat ions to the results of the LFT (e.g.: ICG-t~. vs. Child: r=0.56, p<O.O01). Factor analysis showed that parameters of l i ve r funct ion (Child score, LFT), parameters of nut r i t ion (BCM, BMI, muscle mass, urinary creatinine excretion) as well as metabolic parameters (REE, fuel mix, glucose tolerance)~ were found in different factors with high factor loadings >/0.5.
We conclude that the Child-Pugh score does not ~etect poor nutritional and metabolic status in patients with liver cirrhosis and should be extended accordingly.
Supported by the B. Braun Stiftung Melsungen, Germany.
