Application of Global Leadership Initiative on Malnutrition Criteria in Patients with Liver Cirrhosis
Liver cirrhosis, the end stage of most chronic liver diseases, poses a significant public health burden globally. It is the 14th leading cause of death worldwide, resulting in approximately 1.3 million deaths annually. Malnutrition, a serious public health issue, is a major cause of death and disease. The liver plays a critical role in energy metabolism, and malnutrition is prevalent in patients with liver cirrhosis, particularly those with decompensated cirrhosis. Recognizing the importance of nutritional status, the Global Leadership Initiative on Malnutrition (GLIM) criteria were published in 2019 to establish a global consensus on the diagnosis of malnutrition in various clinical settings. Reduced muscle mass, a key phenotypic criterion in the GLIM criteria, is strongly supported by evidence. However, there is no consensus on how to accurately measure and define reduced muscle mass in clinical settings. This study aimed to investigate the optimal reference values of skeletal muscle mass index for diagnosing sarcopenia and GLIM-defined malnutrition, as well as the prevalence of GLIM-defined malnutrition in hospitalized cirrhotic patients.
This retrospective study included 1002 adult patients with liver cirrhosis hospitalized between January 1, 2018, and February 28, 2022, at Beijing You-An Hospital, Capital Medical University. Patients were included if they had a clinical diagnosis of liver cirrhosis and underwent an abdominal computed tomography (CT) examination during hospitalization. Exclusion criteria included confirmed or suspected malignant tumors, long-term bedridden status, acquired immune deficiency syndrome, pregnancy or lactation, and severe chronic conditions affecting nutrient absorption. Patients were randomly divided into a modeling group (cohort 1, 667 patients) and a validation group (cohort 2, 335 patients). Cohort 1 was used to determine optimal cut-off values of skeletal muscle index at the third lumbar skeletal muscle index (L3-SMI) using receiver operating characteristic (ROC) analyses against in-hospital mortality in different gender groups. Cohort 2 was used to validate the reference values and assess the prevalence of GLIM-defined malnutrition.
Anthropometric measurements, including body weight and height, were taken using standardized methods. Dry body weight was calculated for patients with fluid retention by subtracting a percentage of body weight based on the severity of ascites. The body mass index (BMI) was calculated as dry weight in kilograms divided by height in meters squared. Skeletal muscle mass was assessed using abdominal CT images analyzed with Syngo software. The L3-SMI was calculated as the muscle area at the third lumbar vertebrae divided by height in meters squared, reflecting muscle mass. Nutritional diagnosis followed the GLIM criteria, which include risk screening using the Nutritional Risk Screening 2002 (NRS-2002) and diagnosis based on phenotypic and etiologic criteria. Serum albumin levels below 35 g/L were considered indicative of hypoproteinemia and disease burden.
The study found that the optimal cut-off values of L3-SMI were 39.50 cm2/m2 for male patients and 33.06 cm2/m2 for female patients. Based on these values, 31.63% of male patients and 23.3% of female patients in cohort 2 had CT-determined sarcopenia. The prevalence of GLIM-defined malnutrition in cirrhotic patients was 34.3%, and GLIM-defined malnutrition was an independent risk factor for in-hospital mortality (Wald = 6.347, P = 0.012). Patients with malnutrition had a higher prevalence of complications such as ascites, spontaneous peritonitis (SBP), and in-hospital death compared to those without malnutrition. The study also found that GLIM-defined malnutrition was better than Subjective Global Assessment (SGA) in predicting in-hospital mortality, with a higher area under the ROC curve (AUC = 0.666 for GLIM vs. AUC = 0.505 for SGA).
The study provided reference values for skeletal muscle mass index and the prevalence of GLIM-defined malnutrition in hospitalized patients with liver cirrhosis. These reference values contribute to applying the GLIM criteria in cirrhotic patients and highlight the importance of objective measurement of muscle mass in diagnosing malnutrition and predicting adverse outcomes. The study also demonstrated that GLIM-defined malnutrition is associated with higher in-hospital mortality and poor clinical outcomes in cirrhotic patients.
The findings of this study have several implications for clinical practice. First, the established cut-off values of L3-SMI for diagnosing sarcopenia and GLIM-defined malnutrition provide a standardized approach for assessing nutritional status in cirrhotic patients. Second, the high prevalence of GLIM-defined malnutrition underscores the need for routine nutritional assessment and intervention in this population. Third, the association between GLIM-defined malnutrition and in-hospital mortality highlights the importance of early identification and management of malnutrition to improve patient outcomes.
Despite its contributions, the study has some limitations. The retrospective single-center design may limit the generalizability of the findings, and further multi-regional validation studies are needed. The study focused on short-term outcomes, and future research should investigate the long-term effects of malnutrition in cirrhotic patients. Additionally, the optimal thresholds for severely reduced muscle mass remain unknown, and further research is needed to determine these values.
In conclusion, this study established reference values for skeletal muscle mass index to diagnose sarcopenia and GLIM-defined malnutrition in hospitalized patients with liver cirrhosis. The findings provide preliminary evidence of the effectiveness of GLIM-defined malnutrition in predicting adverse outcomes in this population. Future research should focus on validating these reference values in larger, multi-center studies and exploring the long-term impact of malnutrition in cirrhotic patients.
doi.org/10.1097/CM9.0000000000002937
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