Sarcopenia in Liver Cirrhosis

Sarcopenia in Liver Cirrhosis

1. Sarcopenia in liver cirrhosis Pratap sagar Tiwari Total slides 91

2. Four questions How Sarcopenia develops in liver cirrhosis ? Why management of sarcopenia is crucial ? How to approach a CLD patient for Sarcopenia ? How to manage Sarcopenic patient in CLD ? 2

3. Background The most commonly recognized complications in LC pts include ascites, HE, VH, kidney dysfunction, and HCC ; however, severe muscle wasting or sarcopenia are the MC and frequently unseen complications which negatively impact survival & quality of life. At present, D’Amico stage classification , Child-Pugh, and MELD scores constitute the best tools to predict mortality in pts with LC; however, one of their main limitations is the lack of assessing the nutritional and functional status. Pts with a MELD score <9 have only a 2% 90-day mortality rate, whereas pts with a MELD score of 27 have 50 %, 34 have 75 % and 40 have 90% mortality rate. Damico staging 1 year mortality: stage 1,2,3 & 4 have 1 %, 3.4 %, 20 % and 57 % respectively. 3

4. Review of datas : Ascites The transition from compensated asymptomatic cirrhosis to decompensated cirrhosis occurs at a rate of about 5% to 7% per year. Median survival drops from more than 12 years for compensated cirrhosis to about two years for decompensated cirrhosis . Cirrhosis is the main cause of ascites in the Western world, being responsible for about 80% of cases. Ascites occurs at the rate of 7–10% annually in cirrhotic pts . Ascites is the most common complication of cirrhosis, and 70% of pts with compensated cirrhosis develop ascites within 10 years during the course of their disease. The mortality is approximately 40% at 1 year and 50% at 2 years . Development of RA is a/with a signifcant reduction of survival to 50% at 6 months. 4

5. Review of datas All pts with cirrhosis and ascites are at risk of SBP and the prevalence of SBP in outpts undergoing paracentesis is 3.5% and 10% in hospitalized pts. In pts who survive an episode of SBP, the cumulative recurrence rate at 1 year is approx 70% . The probability of survival at 1 year after an episode of SBP is 50% and falls to 25% at 2 years. Approx 5% to 10% of pts with cirrhosis and ascites develop hepatic hydrothorax , mainly in the right side (85%), but it can also be in the left side(13%) or bilateral(2%). Almost 10% of pts with cirrhosis admitted to the hospital with hepatic hydrothorax have a spontaneous bacterial empyema and 40% of these episodes are not a/with SBP. Median survival of pts with hepatic hydrothorax ranges from 8–12 months. 5

6. Review of datas : HRS HRS develops in approximately 30% of pts who develop SBP . Almost 50% of cirrhotic pts with ascites will develop AKI during the course of their illness. 20% of hospitalized pts with LC had AKI, and among those approx 17% had HRS . 2-week mortality rate as high as 80% in untreated T1 HRS pts with only 10% of pts surviving for 3 months. Prognosis of T2 HRS pts is slightly better, with a median survival of 6 months. 6

7. Review of datas : HE The prevalence of OHE at the time of DX of LC is 10%-14% in general , 16%-21% in those with decompensated LC, and 10%-50% in pts with TIPS . Minimal HE (MHE) or covert HE (CHE) occurs in 20%-80% of pts with cirrhosis . Its occurrence is a poor prognostic indicator, with projected 1- and 3-year survival rates of 42% and 23%, respectively, without liver transplantation. The risk for the first bout of OHE is 25% within 5 years after cirrhosis diagnosis , depending on the presence of risk factors. Subjects with a previous bout of OHE were found to have a 40% cumulative risk of recurring OHE at 1 year , and subjects with recurrent OHE have a 40% cumulative risk of another recurrence within 6 months , despite lactulose treatment. 7

8. Review of datas : VH Esophageal varices appear only after the HVPG has increased to at least 10 to 12 mm Hg . In pts with LC the incidence of EV ↑by nearly 5%/ yr , and the rate of progression from small to LV is approx 5 to 10 % per year EV are present in 40% of pts with compensated LC , and in 60% of pts with ascites . Among Child A, 40 % have varices and among Child C, 85 % have varices. In pts with small varices , the risk of variceal bleeding is approx 7% in 2 years, but in pts with large varices , the risk of bleeding is 30% at 2 years . The mortality rate from variceal bleeding is about 20% at 6 weeks when pts are treated optimally in hospital. Variceal bleeding is a/with a >50% risk of death within 1 year. 8

9. Review of datas : HCC Without treatment, Median overall survival by BCLC stage (months) for 0/A, B,C,D is 13.6, 9.5, 3.4 and 1.8 months respectively. 5 year survival is less than 5 % without treatment. With appropriate treatment, 5 year median overall survival in BLCL stage 0/A, B,C,D is >60 , 20, 11 and <3 months respectively. 9

10. Malnutrition Malnutrition is frequently a burden in pts with LC, occurring in 20–50% of pts . The progression of malnutrition is a/with that of liver failure. While malnutrition may be less evident in pts with compensated cirrhosis it is easily recognisable in those with DLC. Malnutrition has been reported in 20% of pts with compensated cirrhosis and in >50% of pts with DLC .[1] Both adipose tissue and muscle tissue can be depleted; female pts more frequently develop a depletion in fat deposits while males more rapidly lose muscle tissue.[1,2] Nutritional status in cirrhosis. Italian multicentre cooperative project on nutrition in liver cirrhosis. J Hepatol 1994;21:317–325. Caregaro L, Alberino F, Amodio P, Merkel C, Bolognesi M, Angeli P, et al. Malnutrition in alcoholic and virus-related cirrhosis. Am J Clin Nutr 1996;63:602–609. 10

11. Common terms Box 1. Terminology and definitions. Malnutrition A nutrition-related disorder resulting from lack of intake or uptake of nutrition that leads to altered body composition (↓ fat free mass) and body cell mass, leading to ↓ physical and mental function and impaired clinical outcome from disease . In this presentation, I have used “malnutrition” as a synonym of “undernutrition”. Undernutrition Synonym of malnutrition (see above) Muscle wasting The active, progressive loss of muscle mass due to an underlying disease , ultimately leading to muscle atrophy. Severe form of muscle wasting is Cachexia. Sarcopenia A generalised reduction in muscle mass and function due to aging (primary sarcopenia), acute or chronic illness (secondary sarcopenia), including CLD. Frailty Loss of functional, cognitive, and physiologic reserve leading to a vulnerable state . Frailty may be considered a form of nutrition-related disorder. Immunonutrition Use of specific nutrients in an attempt to modulate the immune system . Examples include enteral nutritional formulas enriched with Ω -3 fatty acids, arginine, glutamine and nucleotides. Deconditioning Deterioration of muscle functional capacity related to immobility and chronic debilitating disease. 11

12. Introduction: Sarcopenia Sarcopenia is a syndrome characterised by progressive and generalized loss of skeletal muscle mass and strength with a risk of adverse outcomes such as physical disability, poor QOL and, ultimately, death [1]. It is a reduction in muscle mass two standard deviations below the healthy young adult.[4] Cruz- Jentoft , A.J.; Baeyens , J.P.; Bauer, J.M.; Boirie , Y.; Cederholm, T.; Landi , F.; Martin, F.C.; Michel, J.P.; Rolland, Y.; Schneider, S.M.; et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European working group on sarcopenia in older people. Age Ageing 2010, 39, 412–423. Tsochatzis , E.A.; Bosch, J.; Burroughs, A.K. Liver cirrhosis. Lancet 2014, 383, 1749–1761. Ryall, J.G.; Schertzer , J.D.; Lynch, G.S. Cellular and molecular mechanisms underlying age-related skeletal muscle wasting and weakness. Biogerontology 2008, 4, 213–228. Baumgartner RN, Koehler KM, Gallagher D, Romero L, Heymsfield SB, Ross RR, Garry PJ, Lindeman RD. Epidemiology of sarcopenia among the elderly in New Mexico. Am J Epidemiol 1998; 147: 755-763 The first manifestation is atrophy : the muscle progressively reduces its size, muscle fibres are replaced by fat and fibrous tissue, with increased oxidative stress, muscle metabolism changes, and NMJ degeneration arises, leading to progressive loss of muscle function and frailty [2,3]. 12

13. 1. How Sarcopenia develops in Liver Cirrhosis ? 13

14. Inadequate dietary intake and its consequences ↓ Dietary intake due to a variety of factors including Dysgeusia(zinc def)/nausea/early satiety (ascites/splenomegaly) Anorexia of chronic disease (upregulation of TNF-a, Leptin) Salt restricted food that is not tasty PHTN that contributes to impaired gut motility, ↓ nutrient absorption and protein losing enteropathy Additional factors that result in ↓ dietary intake include Inappropriate dietary protein restriction Hospitalisation with periods of fasting for diagnostic and therapeutic procedures HE GIB Accelerated starvation Aggravates Protein synthesis is ↓ Gluconeogenesis from amino acids is ↑ Proteolysis (contributes to sarcopenia) Cirrhosis is a state of accelerated starvation characterised by a reduction in the respiratory quotient . The reduction in the RQ is the manifestation of a metabolic switch in the primary fuel from glucose to fatty acids . Gluconeogenesis is an energy-expensive procedure which may further ↑ ‘Resting energy expenditure’ (REE) . Energy supply needs to balance ‘total energy expenditure’ (TEE), which includes REE, food-related thermogenesis and energy expenditure related to physical activity. In cirrhotic pts, TEE varies between 28 to 37.5 kcal/kg.BW/d. 14

15. Intestinal changes in advanced LC The passage of viable bacteria from the intestinal lumen through the intestinal wall as well as to mesenteric LN and other sites, defined as BT, generally explains the cause of bacterial infections , which increase mortality 4-fold in pts with LC [1]. The concept of BT was later broadened to include microbial products and/or their fragments, such as endotoxin and bacterial DNA [1]. Small bowel dysmotility, SIBO and intestinal hyperpermeability are mutually related and finally lead to pathological increases in BT. Fukui H. Gut-liver axis in liver cirrhosis: how to manage leaky gut and endotoxemia. World J Hepatol. 2015;7:425–442. Cheung, K.; Lee, S.S.; Raman, M. Prevalence and mechanisms of malnutrition in patients with advanced liver disease, and nutrition management strategies. Clin. Gastroenterol. Hepatol. 2012, 10, 117–125. Malabsorption of nutrients in pts with cirrhosis may also be a consequence of chronic pancreatitis , as a result of alcohol abuse, or intraluminal bile acid deficiency , because of its ↓ production, and overgrowth of bacteria in the intestine [2]. 15

16. Decrease intake Intestinal changes/malabsorption Hypermetabolic state Accelerated starvation Metabolic switch to proteolysis 16

17. Sarcopenia and Physical inactivity Nevertheless, it is clear that muscle wasting ↑ fatigue, reducing the possibility of practising physical exercise and finally leading to the worsening of sarcopenia through inactivity. Moreover, the severity of liver disease appears to be related to the extent and severity of sarcopenia and cardiomyopathy and finally to a consequent reduction in exercise capacity [1]. Jones, J.C.; Coombes, J.S.; Macdonald, G.A. Exercise capacity and muscle strength in patients. with cirrhosis. Liver Transpl . 2012 , 18 , 146–151. 17

18. NORMAL SKELETAL MUSCLE REGULATION Note: Satellite cells  are small, mononuclear  cells  found in close a/with striated skeletal  muscles cells  (myofibers). A critical role for these  cells  in the process of  muscle  regeneration has been clearly established. Muscle protein synthesis Physical exercise, leucine-enriched BCAAs, testosterone, insulin and IGF-1 upregulates protein kinase B leading to mTOR activation inside the muscle cell which in turn via activation of various intracellular pathways stimulates muscle protein synthesis [1]. Satellite cell differentiation and proliferation Myostatin , a negative regulator of satellite cells proliferation and differentiation [2] maintain the activity of satellite cells in a quiescent state within the muscle. Ammonia in muscles stimulates myostatin thereby preventing muscle growth [3]. Drummond MJ, Dreyer HC, Fry CS, Glynn EL, Rasmussen BB. Nutritional and contractile regulation of human skeletal muscle protein synthesis and mTORC1 signaling. J Appl Physiol (1985) 2009;106:1374-1384. Garikipati DK, Rodgers BD. Myostatin inhibits myosatellite cell proliferation and consequently activates differentiation: evidence for endocrine-regulated transcript processing. J Endocrinol 2012;215:177-187. Olde Damink SW, Jalan R, Dejong CH. Interorgan ammonia trafficking in liver disease. Metab Brain Dis 2009;24:169-181. Note : mTOR is a protein kinase that regulates protein synthesis and cell growth in response to growth factors, nutrients, energy levels, and stress (Marin et al, 2011) A B 18

19. NORMAL SKELETAL MUSCLE REGULATION Muscle proteolysis Myostatin stimulates both ubiquitin-proteasome pathway (UPP) and autophagy . Hyperammonemia, inactivity and systemic inflammation also activate the UPP [1]. Deranged mitochondrial function and ↑ in ROS generation also activate autophagy leading to proteolysis. Thapaliya S, Runkana A, McMullen MR, Nagy LE, McDonald C, Naga Prasad SV, et al. Alcohol-induced autophagy contributes to loss in skeletal muscle mass. Autophagy 2014;10:677-690. C 19

20. Cirrhosis and hypogonadism Hypogonadism, defined by low free testosterone , occurs in 70–80% of pts with CLD, with evidence of both primary testicular failure and disruption of the hypothalamic-pituitary gonadal (HPG) regulation [1]. The pathogenesis of hypogonadism in LC is complex, and is hypothesized to be mediated in part by toxic metabolites affecting the HPG axis, hyperestrogenemia , and altered protein synthesis . However, hypogonadism in the setting of ALD may also be due to testicular damage . In particular, ethanol and its metabolites have been shown to exert a toxic effect on Leydig cells and are involved in onset of the fibrogenic processes . Elevation in estrogen in conjunction with ↓ testosterone levels results in an ↑ estrogen/androgen ratio , felt to contribute to feminizing features of LC, including gynecomastia, spider angiomatas , palmar erythema. Handelsman DJ, Strasser S, McDonald JA, Conway AJ, McCaughan GW. Hypothalamic-pituitary-testicular function in end-stage nonalcoholic liver disease before and after liver transplantation. Clin Endocrinol ( Oxf ) 1995;43:331-337. 20

21. Total testosterone, free testosterone, and SHBG in various chronic liver diseases 21

22. Proposed mechanisms for hypogonadism in the setting of alcoholic liver disease Alcohol is postulated to affect the hypothalamus/pituitary via attenuation of LH pulsatility , though the role of GnRH pulsatility remains unclear at this time. Alcohol also affects the testes with inhibition of conversion of retinol to retinal (important in spermatogenesis), inhibition of multiple enzymes necessary for testosterone biosynthesis, and downregulation of LH and GABA receptors. Alcohol additionally acts peripherally via increased aromatization of testosterone to estrogen in the setting of portosystemic shunting of androgens and increased conversion to active estrogen forms, overall resulting in higher relative estrogen levels. 22

23. Testosterone and muscle mass Testosterone improves muscle mass and ↑ protein synthesis by ↑ levels of insulin-like growth factor-1 (IGF-1) and consequent mammalian target of rapamycin (mTOR) activation. Testosterone also inhibits myostatin production that leads to less inhibition of muscle satellite cell activity [3]. Handelsman DJ, Strasser S, McDonald JA, Conway AJ, McCaughan GW. Hypothalamic-pituitary-testicular function in end-stage nonalcoholic liver disease before and after liver transplantation. Clin Endocrinol ( Oxf ) 1995;43:331-337. Grossmann M, Hoermann R, Gani L, Chan I, Cheung A, Gow PJ, et al. Low testosterone levels as an independent predictor of mortality in men with chronic liver disease. Clin Endocrinol ( Oxf ) 2012;77:323-328. Orr R, Fiatarone Singh M. The anabolic androgenic steroid oxandrolone in the treatment of wasting and catabolic disorders: review of efficacy and safety. Drugs 2004;64:725-750. More than 80% of advanced LC has low testosterone levels [1]. Serum testosterone levels correlate with muscle mass in men [2]. 23

24. Sarcopenia and hyperammonia Multiple organs are involved in the whole body homeostasis of ammonia, with the liver being a key site [1]. As cirrhosis leads to a decline in the capacity of the liver to detoxify ammonia, skeletal muscle plays a compensatory role in ammonia metabolism and clearance. The skeletal muscle contains the enzyme glutamine synthetase , which removes ammonia via amidation of glutamate into glutamine. Wright G, Noiret L, Olde Damink SW, et al. Interorgan ammonia metabolism in liver failure: the basis of current and future therapies. Liver Int 2011;31:163–175 Kumar A, Davuluri G, Silva RNE, et al. Ammonia lowering reverses sarcopenia of cirrhosis by restoring skeletal muscle proteostasis . Hepatology 2017;65:2045–2058 A recent animal model showed that RX of hyperammonemia improved skeletal muscle strength and mass [2]. 24

25. Consequences of hyperammonemia In the skeletal muscle, ammonia enters the muscle cell, by the Rh B glycoprotein class of ammonia transporters. Hyperammonemia leads to myostatin expression via NF-κB-dependent toll-like receptor pathway. Ammonia also inhibits mTOR directly through 5’-adenosine monophosphate protein kinase dependent pathway [1]. Possible mechanisms for activation of autophagy may include ammonia mediated mitochondrial dysfunction and generation of reactive oxygen species [2]. Zietz B, Lock G, Plach B, Drobnik W, Grossmann J, Schölmerich J, et al. Dysfunction of the hypothalamic-pituitary- glandular axes and relation to Child-Pugh classification in male patients with alcoholic and virus-related cirrhosis. Eur J Gastroenterol Hepatol 2003;15:495-501. Kosenko E, Venediktova N, Kaminsky Y, Montoliu C, Felipo V. Sources of oxygen radicals in brain in acute ammonia intoxication in vivo. Brain Res 2003;981:193-200. 25

26. Sarcopenic obesity With the increasing prevalence of obesity and NASH-related cirrhosis , attention needs to be paid to obesity in pts with cirrhosis. “Obesity does not rule out malnutrition. “ The combination of loss of skeletal muscle and gain of adipose tissue is termed sarcopenic obesity and is observed in a significant number of pts with cirrhosis.[1-3] Moreover, post-transplant obesity and metabolic syndrome are common and weight gain after LT is considered to be primarily due to an ↑ in the adipose tissue, with concomitant loss in skeletal muscle.[3,4] Montano- Loza AJ, Angulo P, Meza-Junco J, Prado CM, Sawyer MB, Beaumont C, et al. Sarcopenic obesity and myosteatosis are associated with higher mortality in patients with cirrhosis. J Cachexia Sarcopenia Muscle 2016;7:126–135. Carias S, Castellanos AL, Vilchez V, Nair R, Dela Cruz AC, Watkins J, et al. Nonalcoholic steatohepatitis is strongly associated with sarcopenic obesity in patients with cirrhosis undergoing liver transplant evalua - tion . J Gastroenterol Hepatol 2016;31:628–633. Choudhary NS, Saigal S, Saraf N, Mohanka R, Rastogi A, Goja S, et al. Sarcopenic obesity with metabolic syndrome: a newly recognized entity following living donor liver transplantation. Clin Transplant 2015;29:211–215. Dasarathy S. Posttransplant sarcopenia: an underrecognized early consequence of liver transplantation. Dig Dis Sci 2013;58:3103–3111. Schiavo, L.; Busetto , L.; Cesaretti , M.; Zelber-Sagi Deutsch, L.; Iannelli , A. Nutritional issues in patients with obesity and cirrhosis. World J. Gastroenterol. 2018, 24, 3330–3346. Sarcopenic obesity is present in 20%–40% of liver transplant candidates and is strongly associated with NAFLD as the primary cause of cirrhosis [5]. 26

27. Sarcopenic obesity Therefore, malnutrition needs to be estimated routinely and treated in the obese cirrhotic pt. In clinical practice, BMI is adequate to recognise obesity (defined as BMI ≥30 kg/m 2 ) in cirrhotic pts, in the absence of fluid retention. In the case of fluid retention, BW needs to be corrected by evaluating the pt’s dry weight , commonly by subtracting a percentage of weight based upon the severity of ascites (mild 5%; moderate 10%; severe 15%), with an additional 5% subtracted if bilateral pedal oedema is present.[1,2] The dry-weight BMI is then calculated. Tandon P, Ney M, Irwin I, Ma MM, Gramlich L, Bain VG, et al. Severe muscle depletion in patients on the liver transplant wait list: its prevalence and independent prognostic value. Liver Transpl 2012;18:1209–1216. Tandon P, Low G, Mourtzakis M, Zenith L, Myers RP, Abraldes JG, et al. A model to identify sarcopenia in patients with cirrhosis. Clin Gastroen - terol Hepatol 2016;14:e1473. 27

28. Insulin resistance is linked both with excess fat tissue and sarcopenia , given that skeletal muscle is one of the major target tissues of insulin action [1]. However, insulin resistance is not the only factor involved in the development of hepatic steatosis and other hormones have effects on body composition, lipid and glucose homeostasis. GH and IGF-1 may be involved and this could explain the interrelationship between liver steatosis and sarcopenia [1]. Several studies showed how GH secretion is blunted in obese subjects , with GH and IGF-1 linked to fatty infiltration of the liver [1]. Moreover , ectopic fat deposition has proven to be a/with reduced GH levels . [1]. Poggiogalle , E.; Lubrano , C.; Gnessi , L.; Mariani , S.; Lenzi , A.; Donini , L.M. Fatty liver index associates with relative sarcopenia and GH/IGF-1 status in obese subjects. PLoS ONE 2016, 11, e0145811. 28

29. Both anorexia and obesity worsen sarcopenia . Anorexia and a ↓ dietary intake ↓ the nutritional components which are essential for movement, while obesity contributes to worsening sedentary life . Fat deposits, which are also able to produce proinflammatory adipokines , and inflammatory consequences, such as a catabolic effect on muscle mass [1-4]. Prado, C.M.; Wells, J.C.; Smith, S.R.; Stephan, B.C.; Siervo , M. Sarcopenic obesity: A critical appraisal of the current evidence. Clin Nutr . 2012, 31, 583–601. Kob , R.; Bollheimer , L.C.; Bertsch, T.; Fellner , C.; Djukic , M.; Sieber , C.C.; Fischer, B.E. Sarcopenic obesity: Molecular clues to a better understanding of its pathogenesis? Biogerontology 2015, 16, 15–29. Porter Starr, K.N.; McDonald, S.R.; Bales, C.W. Obesity and physical frailty in older adults: A scoping review of lifestyle intervention trials. J. Am. Med. Dir. Assoc. 2014, 15, 240–250. Biolo , G.; Cederholm, T.; Muscaritoli , M. Muscle contractile and metabolic dysfunction is common feature of sarcopenia of aging and chronic diseases: From sarcopenic obesity to cachexia. Clin. Nutr . 2014, 33, 737–748. 29

30. 30

31. Mechanisms and potential targets for anabolic resistance and dysregulated proteostasis resulting in sarcopenia and/or failure to respond to standard supplementation. Adapted from Dasarathy S. et al. 2016.65 31

32. 2. Why management of sarcopenia is crucial ? 32

33. CLINICAL IMPACT OF SARCOPENIA Effect of sarcopenia on survival in pts with LC The survival rates of pts with LC are significantly lower in those with sarcopenia than in those without. The median survival is 19 ± 6 mo in pts with sarcopenia , compared to 34 ± 11 mo in pts without sarcopenia ( P = 0.005)[1]. The 1-year probability of survival in pts with sarcopenia is significantly lower than that in pts without sarcopenia (85% vs 97%, P = 0.01[2]; 52% vs 82%, P = 0.003[3]; 53% vs 83%, P = 0.005[4]; 63% vs 79%, P = 0.04[5]). Montano- Loza AJ, Meza-Junco J, Prado CM, Lieffers JR, Baracos VE, Bain VG, Sawyer MB. Muscle wasting is associated with mortality in patients with cirrhosis. Clin Gastroenterol Hepatol 2012; 10: 166-173, 173.e1 Hanai T, Shiraki M, Nishimura K, Ohnishi S, Imai K, Suetsugu A, Takai K, Shimizu M, Moriwaki H. Sarcopenia impairs prognosis of patients with liver cirrhosis. Nutrition 2015; 31: 193-199 Meza-Junco J, Montano- Loza AJ, Baracos VE, Prado CM, Bain VG, Beaumont C, Esfandiari N, Lieffers JR, Sawyer MB. Sarcopenia as a prognostic index of nutritional status in concurrent cirrhosis and hepatocellular carcinoma. J Clin Gastroenterol 2013; 47: 861-870 Montano- Loza AJ, Meza-Junco J, Prado CM, Lieffers JR, Baracos VE, Bain VG, Sawyer MB. Muscle wasting is associated with mortality in patients with cirrhosis. Clin Gastroenterol Hepatol 2012; 10: 166-173, 173.e1 Meza-Junco J, Montano- Loza AJ, Baracos VE, Prado CM, Bain VG, Beaumont C, Esfandiari N, Lieffers JR, Sawyer MB. Sarcopenia as a prognostic index of nutritional status in concurrent cirrhosis and hepatocellular carcinoma. J Clin Gastroenterol 2013; 47: 861-870 33

34. Causes of mortality in pts with sarcopenia and LC The lower survival rate in cirrhotic pts with sarcopenia is thought to be related to a higher proportion of sepsis-related deaths . The sepsis-related mortality rates in pts with and without sarcopenia pts are 22% and 8%, respectively ( P = 0.02)[1]. The risk of infection is higher in elderly pts with sarcopenia than in those without; therefore, sarcopenia , which reflects impaired immunity, may ↑ the risk for severe infections in pts with LC [2]. However, other studies have reported no difference in the frequency of sepsis-related death between pts with and without sarcopenia [3-5] Conflicting results on causes of death call for further research regarding the pathogenic mechanism of sarcopenia in the prognosis of LC. Montano- Loza AJ, Meza-Junco J, Prado CM, Lieffers JR, Baracos VE, Bain VG, Sawyer MB. Muscle wasting is associated with mortality in patients with cirrhosis. Clin Gastroenterol Hepatol 2012; 10: 166-173, 173.e1 Merli M, Lucidi C, Giannelli V, Giusto M, Riggio O, Falcone M, Ridola L, Attili AF, Venditti M. Cirrhotic patients are at risk for health care-associated bacterial infections. Clin Gastroenterol Hepatol 2010; 8: 979-985 Hanai T, Shiraki M, Nishimura K, Ohnishi S, Imai K, Suetsugu A, Takai K, Shimizu M, Moriwaki H. Sarcopenia impairs prognosis of patients with liver cirrhosis. Nutrition 2015; 31: 193-199 Tandon P, Ney M, Irwin I, Ma MM, Gramlich L, Bain VG, Esfandiari N, Baracos V, Montano- Loza AJ, Myers RP. Severe muscle depletion in patients on the liver transplant wait list: its prevalence and independent prognostic value. Liver Transpl 2012; 18: 1209-1216 Meza-Junco J, Montano- Loza AJ, Baracos VE, Prado CM, Bain VG, Beaumont C, Esfandiari N, Lieffers JR, Sawyer MB. Sarcopenia as a prognostic index of nutritional status in concurrent cirrhosis and hepatocellular carcinoma. J Clin Gastroenterol 2013; 47: 861-870 34

35. IMPLICATIONS PRE- AND POST-LIVER TRANSPLANT Sarcopenia Sarcopenia is an independent RF for HE [1] and is linked to an ↑ risk of decompensation . Not surprisingly, it is a/with a 5-fold ↑ risk of mortality , independent of MELDNa score.[2] It is also a/with a 2-fold ↑ risk of waitlist mortality .[5] Following LT, pts with sarcopenia have a significantly longer length of stay in hospital and in ICU .[3,4] Sarcopenia has been shown to be an independent predictor for longer need of mechanical ventilation[4] , implying the connection with respiratory muscle sarcopenia. It is also a/with an ↑ risk of infection [3,4] and an ↑ 12-month mortality post-LT .[4] Bhanji RA, Moctezuma-Velazquez C, Duarte- Rojo A, Ebadi M, Ghosh S, Rose C, Montano- Loza AJ. Myosteatosis and sarcopenia are associated with hepatic encephalopathy in patients with cirrhosis. Hepatol Int 2018. Montano- Loza AJ. Clinical relevance of sarcopenia in patients with cirrhosis. World J Gastroenterol 2014;20:8061-8071. Montano- Loza AJ, Meza-Junco J, Baracos VE, Prado CM, Ma M, Meeberg G, Beaumont C, et al. Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation. Liver Transpl 2014;20:640-648. Kalafateli M, Mantzoukis K, Choi Yau Y, Mohammad AO, Arora S, Rodrigues S, de Vos M, et al. Malnutrition and sarcopenia predict post-liver transplantation outcomes independently of the Model for End-stage Liver Disease score. J Cachexia Sarcopenia Muscle 2017;8:113-121. Tandon P, Ney M, Irwin I, Ma MM, Gramlich L, Bain VG, Esfandiari N, et al. Severe muscle depletion in patients on the liver transplant wait list: its prevalence and independent prognostic value. Liver Transpl 2012;18:1209-1216. 35

36. Post-transplantation survival Several investigators have reported that muscle mass is significantly a/with post-LT mortality. In an analysis, the SMI was significantly a/with post-LT survival (HR = 0.97, P = 0.014)[1]. DiMartini et al [2] demonstrated that muscle mass is a significant predictor of survival in men (HR = 0.95, P = 0.01), but not in women (HR = 0.98, P = 0.55). Englesbe et al [3] showed that the risk of post-LT mortality ↑ as the psoas muscle CSA ↓ (HR = 3.7/1000 mm2 decrease in psoas area; P < 0.0001). Cruz RJ, Dew MA, Myaskovsky L, Goodpaster B, Fox K, Fontes P, DiMartini A. Objective radiologic assessment of body composition in patients with end-stage liver disease: going beyond the BMI. Transplantation 2013; 95: 617-622 DiMartini A, Cruz RJ, Dew MA, Myaskovsky L, Goodpaster B, Fox K, Kim KH, Fontes P. Muscle mass predicts outcomes following liver transplantation. Liver Transpl 2013; 19: 1172-1180 Englesbe MJ, Patel SP, He K, Lynch RJ, Schaubel DE, Harbaugh C, Holcombe SA, Wang SC, Segev DL, Sonnenday CJ. Sarcopenia and mortality after liver transplantation. J Am Coll Surg 2010; 211: 271-278 [PMID: 20670867 Durand F, Buyse S, Francoz C, Laouénan C, Bruno O, Belghiti J, Moreau R, Vilgrain V, Valla D. Prognostic value of muscle atrophy in cirrhosis using psoas muscle thickness on computed tomography. J Hepatol 2014; 60: 1151-1157 Montano- Loza AJ, Meza-Junco J, Baracos VE, Prado CM, Ma M, Meeberg G, Beaumont C, Tandon P, Esfandiari N, Sawyer MB, Kneteman N. Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation. Liver Transpl 2014; 20: 640-648 However, other studies have reported that sarcopenia is not a/with ↑mortality after LT [4,5]. Some differences in the units of measure and definitions of sarcopenia used may partly explain dissimilarities between the results of these studies. Further studies are needed to identify the association between sarcopenia and post-LT survival. 36

37. IMPLICATIONS PRE- AND POST-LIVER TRANSPLANT Cardiac Sarcopenia Over the past few decades many studies have shown LC to be a/with cardiac dysfunction.[1-4] Moreover, cardiovascular complications occur in 25 to 70% of pts after LT [5-7] and are a leading cause of death in this population.[8,9] Limited data [10] has suggested pre LT sarcopenia may be a predictor for the development of cardiomyopathy post LT with an ↑ mortality risk. Additionally, LV dysfunction following LT was a/with significantly lower muscle mass compared to those with normal cardiac function.[11] On the other hand, a retrospective study of 327 pts found no association between sarcopenia and post LT cardiomyopathy.[12] Notably, an ↑ prevalence (36%) of abnormal LV volume index was seen. References are at the end of the slides 37

38. IMPLICATIONS PRE- AND POST-LIVER TRANSPLANT Cardiac Sarcopenia Cirrhotic cardiomyopathy(CCM) is a/with poor outcomes following LT. Diastolic dysfunction pre-LT is a/with a 2-fold ↑ risk of graft failure , and a 1.5-fold ↑ risk of all-cause mortality .[1] Cardiomyopathy is also a/with a 3-fold ↑ risk of developing HF following LT. Of note, CAD is a/with 50% mortality at 1-3 years following LT .[2] RFs for CAD are more prevalent in pts with alcohol related and NASH LC, with 1/3 of cirrhotic pts having non-obstructive CAD (<50% stenosis).[ 2] Intuitively, it makes sense that the presence of both CCM and CAD further compounds risk of cardiovascular complications and mortality , but no studies assessing both entities are available. These studies are needed. Izzy M, Oh J, Watt KD. Cirrhotic Cardiomyopathy After Transplantation: Neither the Transient Nor Innocent Bystander. Hepatology 2018;68:2008-2015. Kwon HM, Hwang GS. Cardiovascular dysfunction and liver transplantation. Korean J Anesthesiol 2018;71:85-91. 38

39. IMPLICATIONS PRE- AND POST-LIVER TRANSPLANT Respiratory Sarcopenia Intuitively, respiratory muscle sarcopenia may contribute to the prolonged mechanical ventilation and ↑ risk of infection post-LT, but no substantiative data exists. Further studies are needed. 39

40. 3. How to approach a CLD patient for Sarcopenia ? 40

41. Nutrition screening tools Simple criteria to stratify pts at high risk of malnutrition is by BMI: being underweight , defined as a BMI < 18.5 kg/m 2 , 20 in which the vast majority of cirrhotic pts have sarcopenia, and having advanced DLC(CP C pts).[1,2] There are several possible scoring tools to classify pts who are at risk of malnutrition. Most have not been validated in cirrhotic pts, and are prone to bias in cases of fluid retention, which should be accounted for. There are two liver disease- specific tools, The Royal Free Hospital-nutritional prioritizing tool (RFH-NPT) score was reported to correlate with clinical deterioration, severity of disease (CP score, MELD score), and clinical complications such as ascites, HRS, and episodes of HE . Furthermore, improvement in RFH-NPT score was a/with improved survival.[3] Tandon P, Raman M, Mourtzakis M, Merli M. A practical approach to nutritional screening and assessment in cirrhosis. Hepatology 2017;65:1044–1057. Tandon P, Ney M, Irwin I, Ma MM, Gramlich L, Bain VG, et al. Severe muscle depletion in patients on the liver transplant wait list: its prevalence and independent prognostic value. Liver Transpl 2012;18:1209–1216. Borhofen SM, Gerner C, Lehmann J, Fimmers R, Gortzen J, Hey B, et al. The royal free hospital-nutritional prioritizing tool is an independent predictor of deterioration of liver function and survival in cirrhosis. Dig Dis Sci 2016;61:1735–1743. 41

42. The Royal Free Hospital-nutritional prioritizing tool (RFH-NPT) score 42

43. The Royal Free Hospital-nutritional prioritizing tool (RFH-NPT) score 43

44. Nutrition screening tools 44

45. Dietary intake assessment Dietary interviews provide practical information for nutritional interventions by identifying what and how much the pt is willing and capable of eating and determining specific nutrient deficiencies that need to be corrected. A detailed assessment of dietary intake is suggested to include: food, fluids, supplements, number of meals and their timing throughout the day (e.g. interval between meals, breakfast and late-night meals as recommended), as well as calories and quality and quantity of protein intake. It should also include barriers to eating: nausea, vomiting, aversion to certain foods, taste, low-sodium diet, early satiety, GI pain and diarrhoea or constipation . Evaluation of dietary intake is time consuming, requires skilled personnel and relies on pt recall and cooperation. 45

46. Dietary intake assessment The best method that relies the least on pt recall is a three-day food diary. However, it requires pts to cooperate and follow detailed instructions, which may make it difficult to implement in those with advanced disease. The 24 h recall technique requires short-term recall, is less burdensome, less likely to alter eating behaviour than food diary, and can be used across diverse populations because it does not require a high level of literacy. At a minimum, pts should be asked if their relative food intake has changed and, if so, by how much (by half etc.) and over what period of time. 46

47. Global assessment tools in cirrhosis The technique of subjective global assessment (SGA) uses data collected during clinical evaluation to determine nutritional status. Overall, SGA has fair to good inter-observer reproducibility 47

48. Assessment tools for Sarcopenia Skeletal muscle mass quantification Skeletal muscle strength Muscle function/physical performance Short physical performance nattery 6-minute walk test Get up and go test ≤ 8 <1 m/s >10 sec Hand grip strength (using dynamometer) Men <30 kg Women <20 kg Similarly, a 6MWT of < 250m has a SN of 90% for identifying pts with ↑ risk for mortality pre-LT.[1] Carey EJ, Steidley DE, Aqel BA, Byrne TJ, Mekeel KL, Rakela J, Vargas HE, et al. Six-minute walk distance predicts mortality in liver transplant candidates. Liver Transpl 2010;16:1373-1378. Body mass assessment BMI/MAMC/MAMA/TSF/DEXA / BIA Nutrition assessment CSA SMI Nutrition screening tools, Dietary assessment, SGA Balance test/ stair climb test etc 48

49. Skeletal muscle mass assessment Many consider skeletal muscle CSI with CT or MRI to be a gold standard tool for DX sarcopenia[1], as these modalities are not influenced by fluid overload or obesity. Some studies use the total psoas area (TPA), by measuring the outline and total surface area of psoas muscle at the level of L3-L4. [2,3] Other studies use the transversal psoas muscle thickness at the level of the umbilicus as it is predictive of mortality in cirrhotic pts independent of MELD and MELDNa .[4] Notably, location of umbilicus may change d/t ascites, affecting reliability of the measure. Recently the L3 SMI was recommended as the method of choice as it correlates best with whole body muscle mass[5] and was superior to psoas muscle measurements and TPA in predicting survival .[6] The suggested cut-offs for L3SMI in pts with cirrhosis are: <50 cm 2 /m 2 in men and <39 cm 2 /m 2 in women. [6] Heymsfield SB. Development of imaging methods to assess adiposity and metabolism. Int J Obes ( Lond ) 2008;32 Suppl 7:S76-82. Krell RW, Kaul DR, Martin AR, Englesbe MJ, Sonnenday CJ, Cai S, Malani PN. Association between sarcopenia and the risk of serious infection among adults undergoing liver transplantation. Liver Transpl 2013;19:1396-1402. Englesbe MJ, Patel SP, He K, Lynch RJ, Schaubel DE, Harbaugh C, Holcombe SA, et al. Sarcopenia and mortality after liver transplantation. J Am Coll Surg 2010;211:271-278. Durand F, Buyse S, Francoz C, Laouenan C, Bruno O, Belghiti J, Moreau R, et al. Prognostic value of muscle atrophy in cirrhosis using psoas muscle thickness on computed tomography. J Hepatol 2014;60:1151-1157. Shen W, Punyanitya M, Wang Z, Gallagher D, St-Onge MP, Albu J, Heymsfield SB, et al. Total body skeletal muscle and adipose tissue volumes: estimation from a single abdominal cross-sectional image. J Appl Physiol (1985) 2004;97:2333-2338. Carey EJ, Lai JC, Wang CW, Dasarathy S, Lobach I, Montano- Loza AJ, Dunn MA, et al. A multicenter study to define sarcopenia in patients with end-stage liver disease. Liver Transpl 2017;23:625-633. 49

50. Assessment tools for Sarcopenia Skeletal muscle mass quantification Skeletal muscle strength Muscle function/physical performance Short physical performance nattery 6-minute walk test Get up and go test ≤ 8 <1 m/s >10 sec Hand grip strength (using dynamometer) Men <30 kg Women <20 kg Similarly, a 6MWT of < 250m has a SN of 90% for identifying pts with ↑ risk for mortality pre-LT.[1] Carey EJ, Steidley DE, Aqel BA, Byrne TJ, Mekeel KL, Rakela J, Vargas HE, et al. Six-minute walk distance predicts mortality in liver transplant candidates. Liver Transpl 2010;16:1373-1378. Body mass assessment BMI/MAMC/MAMA/TSF/DEXA / BIA Nutrition assessment CSA SMI Nutrition screening tools, Dietary assessment, SGA Balance test/ stair climb test etc 50

51. MAMC/MAMA/TSF Body mass assessment can also be performed by simple bedside anthropometric methods[1] including mid-arm muscle circumference (MAMC, defined as mid-arm circumference minus [triceps skinfold (TSF) X 0.314]),[2] mid-arm muscular area [MAMA = (MAMC) 2 /4 X 0.314] and TSF , which are simple to perform, rapid, low cost, and not affected by the presence of fluid retention. Both MAMC and TSF have a demonstrated prognostic value for mortality among cirrhotic pts, with MAMC having a higher prognostic power than TSF .[3] Mid-arm muscle circumference [MAMC] : mid-arm circumference - [triceps skinfold (TSF) X 0.314]) Mid-arm muscular area [MAMA] = (MAMC) 2 /4 X 0.314 Triceps skinfold [TSF] Plauth M, Cabre E, Riggio O, Assis-Camilo M, Pirlich M, Kondrup J, et al. ESPenteral nutrition guidelines on enteral nutrition: liver disease. Clin Nutr 2006;25:285–294. Tandon P, Low G, Mourtzakis M, Zenith L, Myers RP, Abraldes JG, et al. A model to identify sarcopenia in patients with cirrhosis. Clin Gastroen - terol Hepatol 2016;14:e1473. Alberino F, Gatta A, Amodio P, Merkel C, Di Pascoli L, Boffo G, et al. Nutrition and survival in patients with liver cirrhosis. Nutrition 2001;17:445–450. 51

52. Compared to the DX of sarcopenia by CSI, the predictive value of MAMC was shown to be good, with an AUROC of 0.75 for men and 0.84 for women.[1] In a small sample study, a significant but moderate correlation was observed between CT measurement and MAMC in cirrhotic men (r = 0.48, p < 0.001), but not in women.[2] In addition, low MAMC was found to be an independent predictor of mortality after LT , and in a large sample of the general population, but only among men.[3] Tandon P, Low G, Mourtzakis M, Zenith L, Myers RP, Abraldes JG, et al. A model to identify sarcopenia in patients with cirrhosis. Clin Gastroen - terol Hepatol 2016;14:e1473. Alberino F, Gatta A, Amodio P, Merkel C, Di Pascoli L, Boffo G, et al. Nutrition and survival in patients with liver cirrhosis. Nutrition 2001;17:445–450. Wu LW, Lin YY, Kao TW, Lin CM, Liaw FY, Wang CC, et al. Mid-arm muscle circumference as a significant predictor of all-cause mortality in male individuals. PLoS One 2017;12 e0171707. 52

53. DEXA / BIA Whole body dual-energy X-ray absorptiometry (DEXA) allows measurement of bone mineral density, fat mass and fat-free mass . Radiation exposure, cost and logistics are additional limitations, while water retention may limit the validity of the formula applied to assess body composition . The ability to quantify limb muscle mass , which could be more reliable and has corresponding cut-offs in the healthy population, is an advantage and may overcome the confounding effect of overhydration. Tetrapolar bioelectrical impedance analysis (BIA) uses the two-compartment model, and segmental BIA measurements allow limb non-fat mass quantification. Low cost, portable equipment and ease of use are advantages of BIA. However, the validity of these methods also depends on stable hydration status , which may be altered in pts with LC. 53

54. Assessment tools for Sarcopenia Skeletal muscle mass quantification Skeletal muscle strength Muscle function/physical performance Short physical performance battery 6-minute walk test Get up and go test ≤ 8 <1 m/s >10 sec Hand grip strength (using dynamometer) Men <30 kg Women <20 kg Similarly, a 6MWT of < 250m has a SN of 90% for identifying pts with ↑ risk for mortality pre-LT.[1] Carey EJ, Steidley DE, Aqel BA, Byrne TJ, Mekeel KL, Rakela J, Vargas HE, et al. Six-minute walk distance predicts mortality in liver transplant candidates. Liver Transpl 2010;16:1373-1378. Body mass assessment BMI/MAMC/MAMA/TSF/DEXA / BIA Nutrition assessment CSA SMI Nutrition screening tools, Dietary assessment, SGA Balance test/ stair climb test etc Balance Test Gait Speed Test Chair Stand Test 54

55. Measures of frailty Measures of frailty, defined as pt’s vulnerability to stress, decreased physiologic reserve and functional status deficits[2,3] can also be used in the assessment of cirrhotic pts. Wang CW, Feng S, Covinsky KE, Hayssen H, Zhou LQ, Yeh BM, et al. A comparison of muscle function, mass, and quality in liver transplant candidates: results from the functional assessment in liver transplan - tation study. Transplantation 2016;100:1692–1698. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146–M156. Lai JC, Feng S, Terrault NA, Lizaola B, Hayssen H, Covinsky K. Frailty predicts waitlist mortality in liver transplant candidates. Am J Trans- plant 2014;14:1870–1879. 55

56. The components of a detailed nutritional assessment include evaluation of: muscle mass, global assessment tools and a detailed dietary intake assessment . 56

57. 4. How to manage Sarcopenic patient in CLD ? 57

58. MX principles in CLD pts with Sarcopenia Reducing accelerated starvation Strategies to improve muscle mass in cirrhosis Dietary manipulations Increased physical activity and exercise Hormone replacement therapies Ammonia-lowering strategies and targeting the underlying liver disease 58

59. Reducing accelerated starvation Since the longest inter-meal duration is at night, strategies to shorten nocturnal fasting with a late evening snack have been explored, achieving an improvement in metabolic profile and QOL, although muscle mass did not show consistent improvement.[1] The adoption of a breakfast containing some proteins[2] and a late evening snack[3] to shorten the period of fasting are therefore recommended in cirrhotic pts. Tsien CD, McCullough AJ, Dasarathy S. Late evening snack: exploiting a period of anabolic opportunity in cirrhosis. J Gastroenterol Hepatol 2012;27:430–441. Vaisman N, Katzman H, Carmiel -Haggai M, Lusthaus M, Niv E. Breakfast improves cognitive function in cirrhotic patients with cognitive impairment. Am J Clin Nutr 2010;92:137–140. Plank LD, Gane EJ, Peng S, Muthu C, Mathur S, Gillanders L, et al. Nocturnal nutritional supplementation improves total body protein status of patients with liver cirrhosis: a randomized 12-month trial. Hepatology 2008;48:557–566. 59

60. Protein needs are based on the minimum protein intake required to maintain nitrogen balance. In ALC, nitrogen balance was achieved with intakes of 0.8 g/kg.BW/d .[1] Studies also showed that cirrhotic pts are able to utilise up to 1.8 g/kg.BW/d of protein .[2] In the past, there has been controversy about whether pts suffering from HE should undergo a transient restriction in protein intake, in order to limit the synthesis of ammonium and the deamination of protein to AAA. However, normal to high protein intake does not precipitate HE[3,4] and may even improve mental status.[5,6] Nielsen K, Kondrup J, Martinsen L, Stilling B, Wikman B. Nutritional assessment and adequacy of dietary intake in hospitalized patients with alcoholic liver cirrhosis. Br J Nutr 1993;69:665–679. Nielsen K, Kondrup J, Martinsen L, Dossing H, Larsson B, Stilling B, et al. Long-term oral refeeding of patients with cirrhosis of the liver. Br J Nutr 1995;74:557–567. Fenton JC, Knight EJ, Humpherson PL. Milk-and-cheese diet in portal- systemic encephalopathy. Lancet 1966;287:164–166. Bianchi GP, Marchesini G, Fabbri A, Rondelli A, Bugianesi E, Zoli M, et al. Vegetable versus animal protein diet in cirrhotic patients with chronic encephalopathy. A randomized cross-over comparison. J Intern Med 1993;233:385–392. Gheorghe L, Iacob R, Vadan R, Iacob S, Gheorghe C. Improvement of hepatic encephalopathy using a modified high-calorie high-protein diet. Rom J Gastroenterol 2005;14:231–238. Cordoba J, Lopez- Hellin J, Planas M, Sabin P, Sanpedro F, Castro F, et al. Normal protein diet for episodic hepatic encephalopathy: results of a randomized study. J Hepatol 2004;41:38–43. The recommended protein intake in LC is 1.2–1.5 g/kg.BW/d to prevent loss of muscle mass and reverse muscle loss in those who are sarcopenic. 60

61. Short, practical dietary advice for bedside or outpt clinic use Most of what you have heard/read on the relationship between food and the liver has limited scientific evidence to support it. Generally, healthy eating of a variety of foods is advisable for all pts. Virtually no food other than alcohol actually damages the liver and/or is genuinely CI in pts with CLD. In most pts with CLD, eating an adequate number of calories and protein is much more important than avoiding specific types of food , so it is important that you have a good, varied diet that you enjoy. You should try to split your food intake into 3 main meals (breakfast, lunch and dinner) and 3 snacks (mid-morning, mid-afternoon, late evening) . The late-evening snack is the most important, as it covers the long interval between dinner and breakfast. You should try to eat fruits and vegetables as one regularly does . 61

62. Short, practical dietary advice for bedside or outpt clinic use 6. You should try not to add too much salt to your food. It may take some time to adjust, but it usually gets easier with time. 7. A limited proportion of pts with liver disease have a complication called HE, which may make them tolerate animal protein (meat) less well than vegetable protein (beans, peas etc.) and dairy proteins. Before you make any changes to your protein intake, you should always ask your doctor or dietician. Please do not reduce your total protein intake as it is not advisable in cirrhosis. 8. Some pts with liver disease have other diseases , for example diabetes or overweight/obesity, which require dietary adjustments. Please remember to tell your doctor about all your illnesses and about any dietary advice you have already received from other doctors, nurses or dieticians. 62

63. Strategies to improve muscle mass in cirrhosis A number of potential therapeutic strategies to improve muscle mass in pts with cirrhosis have been evaluated. These include Dietary manipulations Increased physical activity and exercise [1-3] Hormone replacement therapies [4] Ammonia-lowering strategies and targeting the underlying liver disease [5-8] Zenith L, Meena N, Ramadi A, Yavari M, Harvey A, Carbonneau M, et al. Eight weeks of exercise training increases aerobic capacity and muscle mass and reduces fatigue in patients with cirrhosis. Clin Gastroenterol Hepatol 2014;12:e1922. Berzigotti A, Saran U, Dufour JF. Physical activity and liver diseases. Hepatology 2016;63:1026–1040. Berzigotti A, Albillos A, Villanueva C, Genesca J, Ardevol A, Augustin S, et al. Effects of an intensive lifestyle intervention program on portal hypertension in patients with cirrhosis and obesity: the SportDiet study. Hepatology 2017;65:1293–1305. Nagasue N, Yukaya H, Chang YC, Ogawa Y, Kohno H, Ito A. Active uptake of testosterone by androgen receptors of hepatocellular carcinoma in humans. Cancer 1986;57:2162–2167. Gorostiaga EM, Navarro- Amezqueta I, Calbet JA, Sanchez-Medina L, Cusso R, Guerrero M, et al. Blood ammonia and lactate as markers of muscle metabolites during leg press exercise. J Strength Cond Res 2014;28:2775–2785. Takeda K, Takemasa T. Expression of ammonia transporters Rhbg and Rhcg in mouse skeletal muscle and the effect of 6-week training on these proteins. Physiol Rep 2015:3. McDaniel J, Davuluri G, Hill EA, Moyer M, Runkana A, Prayson R, et al. Hyperammonemia results in reduced muscle function independent of muscle mass. Am J Physiol Gastrointest Liver Physiol 2016;310: G163–G170. Kumar A, Davuluri G, Silva RNE, Engelen M, Ten Have GAM, Prayson R, et al. Ammonia lowering reverses sarcopenia of cirrhosis by restoring skeletal muscle proteostasis . Hepatology 2017;65:2045–2058 63

64. Nutritional supplementation Those who are unable to achieve adequate dietary intake with the oral diet (even with oral supplements), short-term enteral or parenteral nutrition should be used to overcome the phase of underfeeding . Enteral feeding has been utilised in malnourished cirrhotic pts admitted to hospital, but despite promising individual studies, systematic meta-analyses have not shown significant benefits in terms of survival.[1-3] There are also conflicting data on the benefits of parenteral nutritional supplementation in pts with cirrhosis, but this is likely to have a beneficial role during prolonged periods of poor oral intake including HE, GIB and impaired gut motility or ileus .[4] Fialla AD, Israelsen M, Hamberg O, Krag A, Gluud LL. Nutritional therapy in cirrhosis or alcoholic hepatitis: a systematic review and meta- analysis. Liver Int 2015;35:2072–2078. Koretz RL, Avenell A, Lipman TO. Nutritional support for liver disease. Cochrane Database Syst Rev 2012 CD008344. Antar R, Wong P, Ghali P. A meta-analysis of nutritional supplemen - tation for management of hospitalized alcoholic hepatitis. Can J Gastroenterol 2012;26:463–467. Plauth M, Cabre E, Campillo B, Kondrup J, Marchesini G, Schutz T, et al. ESPenteral nutrition Guidelines on Parenteral Nutrition: hepatology. Clin Nutr 2009;28:436–444. 64

65. BCAA Oral nutritional supplement and BCAA supplements have been utilised in clinical trials[6,7] showing some benefits. A ↓ serum ratio of BCAA to aromatic amino acids has been a/with a poor prognosis,[1] However, BCAA supplements, in daily divided doses , may facilitate the provision of an adequate nitrogen intake in pts who are intolerant to meat protein .[2,3] The replacement of meat with dairy/vegetable protein plus BCAA supplements is likely to be preferable to a reduction in total protein intake. It has also been shown that L-leucine alone can reverse the ↓ in disturbed muscle protein homeostasis ( proteostasis ) due to hyperammonaemia .[4] A Cochrane meta-analysis included 16 RCTs, comparing oral or iv BCAA supplementation vs. a control intervention in 827 pts with HE.[5] Oral BCAA had a positive impact on HE. However, oral or iv BCAA did not influence mortality, QOL or nutritional status. Their use intravenously for episodic overt HE is not supported by the available evidence. Kawaguchi T, Izumi N, Charlton MR, Sata M. Branched-chain amino acids as pharmacological nutrients in chronic liver disease. Hepatology 2011;54:1063–1070. Holecek M. Three targets of branched-chain amino acid supplementa - tion in the treatment of liver disease. Nutrition 2010;26:482–490. Dam G, Ott P, Aagaard NK, Vilstrup H. Branched-chain amino acids and muscle ammonia detoxification in cirrhosis. Metab Brain Dis 2013;28:217–220. Davuluri G, Krokowski D, Guan BJ, Kumar A, Thapaliya S, Singh D, et al. Metabolic adaptation of skeletal muscle to hyperammonemia drives the beneficial effects of l-leucine in cirrhosis. J Hepatol 2016;65:929–937. Gluud LL, Dam G, Les I, Cordoba J, Marchesini G, Borre M, et al. Branched-chain amino acids for people with hepatic encephalopathy. Cochrane Database Syst Rev 2015 CD001939. Nakaya Y, Harada N, Kakui S, Okada K, Takahashi A, Inoi J, et al. Severe catabolic state after prolonged fasting in cirrhotic patients: effect of oral branched-chain amino-acid-enriched nutrient mixture. J Gastroen - terol 2002;37:531–536. Yoshida T, Muto Y, Moriwaki H, Yamato M. Effect of long-term oral supplementation with branched-chain amino acid granules on the prognosis of liver cirrhosis. Gastroenterol Jpn 1989;24:692–698. In critically ill cirrhotic pts with HE, BCAA-enriched solutions should be used to facilitate resolution.[EASL] 65

66. Micronutrients In general, vitamin deficiencies in liver disease are related to hepatic dysfunction, diminished reserves and, with increasing disease severity , inadequate dietary intake and malabsorption . Fat-soluble vitamin deficiencies are common. A retrospective study reported that the majority of liver disease pts being considered for LT presented with vitamin A and D deficiencies .[1] In pts with CLD, vitamin D (25(OH)D) levels < 20 ng/ml have been reported in between 64 and 92% of pts, predominantly in chronic cholestatic conditions, and usually inversely correlated with more advanced disease and CP score .[2,3] Low vitamin D levels might, in part, be due to ↓ plasma binding proteins in the presence of liver insufficiency. Venu M, Martin E, Saeian K, Gawrieh S. High prevalence of vitamin A deficiency and vitamin D deficiency in patients evaluated for liver transplantation. Liver transpl 2013;19:627–633. Trautwein C, Possienke M, Schlitt HJ, Boker KH, Horn R, Raab R, et al. Bone density and metabolism in patients with viral hepatitis and cholestatic liver diseases before and after liver transplantation. Am J Gastroenterol 2000;95:2343–2351. Stokes CS, Volmer DA, Grunhage F, Lammert F. Vitamin D in chronic liver disease. Liver Int 2013;33:338–352. 66

67. Micronutrients It is advisable to assess plasma vitamin D (25(OH)D) levels in all pts with CLD, particularly in those with advanced disease ,[1,2] NAFLD and cholestatic disorders .[3] Although there are no specific recommendations in pts with CLD except for those with chronic cholestasis, it seems reasonable to supplement all CLD pts with vitamin D levels < 20 ng/ml with oral vitamin D until reaching a serum vitamin D level above 30 ng/ml. Vitamin K deficiency should always be considered in pts who are jaundiced or whose liver disease is cholestatic in origin, and parenteral supplementation might be needed. Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011;96:1911–1930. Stokes CS, Volmer DA, Grunhage F, Lammert F. Vitamin D in chronic liver disease. Liver Int 2013;33:338–352. European Association for the Study of the. L. EASL Clinical Practice Guidelines: management of cholestatic liver diseases. J Hepatol 2009;51:237–267. 67

68. Micronutrients Pts with both alcohol and non-alcohol related LC are prone to deficiencies in water-soluble vitamins, particularly thiamine (B1). They often exhibit evidence at autopsy of WE, even in the absence of a history/ clinical signs during life.[1] If WE is suspected, generous parenteral thiamine supplementation is mandatory . Deficiencies in pyridoxine (B6), folate (B9) and cobalamin (B12) may also develop rapidly in CLD resulting from diminished hepatic storage.[2] However, good quality data on their prevalence and/or need for supplementation are scarce. Kril JJ, Butterworth RF. Diencephalic and cerebellar pathology in alcoholic and nonalcoholic patients with end-stage liver disease. Hepatology 1997;26:837–841. Bemeur C, Butterworth RF. Nutrition in the management of cirrhosis and its neurological complications. J Clin Exp Hepatol 2014;4:141–150. As vitamin status is not easily assessed and multivitamin supplementation is cheap and substantially side effect free, a course of oral multivitamin supplementation could be justified in decompensated pts. 68

69. Others Reductions in circulating levels of calcium, magnesium, and iron need to be considered and corrected.[1] Tissue zinc concentrations are reduced in pts with LC and zinc has been implicated in the pathogenesis of HE. Selenium deficiency has been related to the severity of hepatic fibrosis in pts with hepatitis C and identified as one of the factors contributing to insulin resistance in these pts.[2] Huskisson E, Maggini S, Ruf M. The influence of micronutrients on cognitive function and performance. J Int Med Res 2007;35:1–19. Himoto T, Yoneyama H, Kurokohchi K, Inukai M, Masugata H, Goda F, et al. Selenium deficiency is associated with insulin resistance in patients with hepatitis C virus-related chronic liver disease. Nutr Res 2011;31:829–835. 69

70. Others Pts with cirrhosis have elevated total body manganese levels , which may result in selective manganese accumulation in the basal ganglia .[1] While there is no clear relationship between such a phenomenon and HE, it is probably reasonable to avoid nutritional supplements containing manganese (Dark Chocolate, Avocados, Nuts etc) . Specific evidence about the beneficial effect of micronutrients and vitamin supplementation in cirrhotic pts is not available. However, confirmed or clinically suspected deficiency should be treated based on accepted general recommendations and common practice. Inoue E, Hori S, Narumi Y, Fujita M, Kuriyama K, Kadota T, et al. Portal- systemic encephalopathy: presence of basal ganglia lesions with high signal intensity on MR images. Radiology 1991;179:551–555. 70

71. Nutritional approach and MX of obesity in pts with LC Data from different studies suggest that a reduction in BW improves outcomes in obese pts with compensated cirrhosis.[1-3] Implement a nutritional and lifestyle programme to achieve progressive weight loss (>5–10%) in obese cirrhotic pts (BMI >30 kg/m 2 corrected for water retention). A tailored, moderately hypocaloric (-500–800 kcal/d) diet, including adequate protein intake (>1.5 g proteins/ kg.ideal BW/d) can be adopted to achieve weight loss without compromising protein stores in obese cirrhotic pts. Zenith L, Meena N, Ramadi A, Yavari M, Harvey A, Carbonneau M, et al. Eight weeks of exercise training increases aerobic capacity and muscle mass and reduces fatigue in patients with cirrhosis. Clin Gastroenterol Hepatol 2014;12:e1922. Everhart JE, Lok AS, Kim HY, Morgan TR, Lindsay KL, Chung RT, et al. Weight-related effects on disease progression in the hepatitis C antiviral long-term treatment against cirrhosis trial. Gastroenterology 2009;137:549–557. Macias-Rodriguez RU, Ilarraza -Lomeli H, Ruiz- Margain A, Ponce-de- Leon-Rosales S, Vargas- Vorackova F, Garcia-Flores O, et al. Changes in hepatic venous pressure gradient induced by physical exercise in cirrhosis: results of a pilot randomized open clinical trial. Clin Transl Gastroenterol 2016;7:e180. 71

72. Exercise and physical activity In addition to nutritional supplementation, increased physical activity and exercise are also anabolic stimuli that can improve muscle mass and function. However, consistent long-term data in cirrhosis are lacking.[1,2] Endurance or aerobic exercise improves skeletal muscle functional capacity but not necessarily muscle mass.[3] Resistance exercise promotes an ↑ in skeletal muscle mass.[3] Since both muscle loss and impaired contractile function are components of sarcopenia in cirrhosis , a combination of resistance and endurance exercise would probably be appropriate and beneficial, as confirmed by emerging data indicating the benefit of a moderate intensity exercise regimen in cirrhosis.[4] Rennie MJ, Tipton KD. Protein and amino acid metabolism during and after exercise and the effects of nutrition. Annu Rev Nutr 2000;20:457–483. Liao CD, Tsauo JY, Wu YT, Cheng CP, Chen HC, Huang YC, et al. Effects of protein supplementation combined with resistance exercise on body composition and physical function in older adults: a systematic review and meta-analysis. Am J Clin Nutr 2017;106:1078–1091. Baar K. Training for endurance and strength: lessons from cell signaling. Med Sci Sports Exerc 2006;38:1939–1944. Berzigotti A, Albillos A, Villanueva C, Genesca J, Ardevol A, Augustin S, et al. Effects of an intensive lifestyle intervention program on portal hypertension in patients with cirrhosis and obesity: the SportDiet study. Hepatology 2017;65:1293–1305. A minimum of 30 min of moderate intensity exercise (combined aerobic and resistance in a 3:2 ratio) per day for 3–5 times per week is recommended. 72

73. Hormone replacement therapy Hormone replacement therapy utilising growth hormone or testosterone has been proposed but has not been consistently effective.[1-4] Furthermore caution is needed when using testosterone because of the possibility of increasing the risk of HCC .[5] Sinclair M, Grossmann M, Hoermann R, Angus PW, Gow PJ. Testosterone therapy increases muscle mass in men with cirrhosis and low testos - terone : a randomised controlled trial. J Hepatol 2016;65:906–913. Assy N, Hochberg Z, Amit T, Shen-Orr Z, Enat R, Baruch Y. Growth hormone-stimulated insulin-like growth factor (IGF) I and IGF-binding protein-3 in liver cirrhosis. J Hepatol 1997;27:796–802. Matsumoto R, Fukuoka H, Iguchi G, Nishizawa H, Bando H, Suda K, et al. Long-term effects of growth hormone replacement therapy on liver function in adult patients with growth hormone deficiency. Growth Horm IGF Res 2014;24:174–179. Sinclair M, Gow PJ, Grossmann M, Angus PW. Review article: sarcope - nia in cirrhosis– aetiology , implications and potential therapeutic interventions. Aliment Pharmacol Ther 2016;43:765–777. Nagasue N, Yukaya H, Chang YC, Ogawa Y, Kohno H, Ito A. Active uptake of testosterone by androgen receptors of hepatocellular carcinoma in humans. Cancer 1986;57:2162–2167. 73

74. Ammonia-lowering strategies Long-term ammonia-lowering strategies may result in ↑ed muscle mass and contractile strength but the data are derived from preclinical studies and require validation in human studies.[1] A combination of rifaximin and LOLA ↓ plasma and muscle ammonia concentrations and improved muscle mass in an experimental model of hyperammonemia. Decrease in gastrocnemius muscle fiber size was partially reversed with a significant ↑ in the type II fibers. Ammonia-lowering therapy ↓ expression of myostatin, autophagy markers and mTOR signaling which were altered by skeletal muscle hyperammonemia.[2] Kumar A, Davuluri G, Silva RNE, Engelen M, Ten Have GAM, Prayson R, et al. Ammonia lowering reverses sarcopenia of cirrhosis by restoring skeletal muscle proteostasis . Hepatology 2017;65:2045–2058. Kumar A, Davuluri G, Silva RNE, et al. Ammonia lowering reverses sarcopenia of cirrhosis by restoring skeletal muscle proteostasis . Hepatology. 2017;65:2045–58. 74

75. Ammonia-lowering strategies: L-Carnitine Carnitine plays an important role in fatty acid oxidation and around 25% of it is produced by the kidney and liver. L-Carnitine (1000 mg/day) administration for >6 months suppressed skeletal muscle loss in pts with LC . Ability of L-carnitine to ↓ ammonia levels and improve mitochondrial function may contribute to prevention of skeletal muscle mass loss in pts with LC.[1] However, recent studies found that suppression of sarcopenia progression by L-carnitine in LC seems to be dose dependent and administration of high-dose L-carnitine (1274 mg/day) was a/with ↓ in serum ammonia levels at a year following administration .[2] Malaguarnera M, Vacante M, Giordano M, et al. Oral acetyl- Lcarnitine therapy reduces fatigue in overt hepatic encephalopathy: a randomized, double-blind, placebo-controlled study. Am J Clin Nutr . 2011;93:799–808. Hiramatsu A, Aikata H, Uchikawa S, et al. Levocarnitine use is associated with improvement in sarcopenia in patients with liver cirrhosis. Hepatol Comm. 2019;3:348–55. 75

76. Hyponatraemia Hyponatraemia is common in pts with LC and is more likely to occur when the intake of sodium is low, and that of water unchanged or increased.[1] Thus, careful monitoring of both sodium and water intake is required . If severe hyponatraemia is corrected, this needs to be done slowly, to avoid the risk of CPM.[2] A reduction in dietary sodium intake is recommended in pts with ascites,[5] although evidence in this respect is limited and conflicting.[3] Sodium intake should certainly not be reduced below 60 mmol/d , as this makes the diet unpalatable, potentially compromising energy and protein intake.[4] Cosgray RE, Hanna V, Davidhizar RE, Smith J. The water-intoxicated patient. Arch Psychiatr Nurs 1990;4:308–312. Kleinschmidt- DeMasters BK, Norenberg MD. Rapid correction of hyponatremia causes demyelination: relation to central pontine myeli - nolysis . Science 1981;211:1068–1070. Gu XB, Yang XJ, Zhu HY, Xu BY. Effect of a diet with unrestricted sodium on ascites in patients with hepatic cirrhosis. Gut Liver 2012;6:355–361. Morando F, Rosi S, Gola E, Nardi M, Piano S, Fasolato S, et al. Adherence to a moderate sodium restriction diet in outpatients with cirrhosis and ascites: a real-life cross-sectional study. Liver Int 2015;35:1508–1515. European Association for the Study of the L. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010;53:397–417. 76

77. Immunonutrition Immunonutrition i.e. nutritional solutions enriched with Ω-3 fatty acids, arginine and nucleotides, has also been proposed. One retrospective study examined pts undergoing elective liver resection, who received preoperative oral immunonutrition for 7 days (n = 84; 14 pts with cirrhosis) vs. no oral supplementation (n = 63, 5 pts with cirrhosis). The authors found no impact on postoperative complications. [1] When considering the components of immunonutrition separately, oral Ω -3 fatty acids administered to cirrhotic pts with ascites and renal failure did not improve renal function but increased bleeding time and arterial blood pressure , leading the authors to argue against their use in cirrhotic pts.[2] Zacharias T, Ferreira N, Carin AJ. Preoperative immunonutrition in liver resection-a propensity score matched case-control analysis. Eur J Clin Nutr 2014;68:964–969. Badalamenti S, Salerno F, Salmeron JM, Lorenzano E, Rimola A, Gines P, et al. Lack of renal effects of fish oil administration in patients with advanced cirrhosis and impaired glomerular filtration. Hepatology 1997;25:313–316. 77

78. Nutritional support in gastrointestinal bleeding In a randomised study, 22 pts with LC were administered enteral nutrition by a NG tube or no oral intake during the first four days after acute bleeding from EV.[1] No difference in re-bleeding, nutritional status, liver function, duration of hospital stay and mortality was observed between the groups after a follow-up of 35 days. Nevertheless, experts recommend withholding enteral nutrition for 48–72 h after acute bleeding,[2,3] because enteral nutrition increases splanchnic blood flow, which in turn may increase PP and the risk of variceal re-bleeding. de Ledinghen V, Beau P, Mannant PR, Borderie C, Ripault MP, Silvain C, et al. Early feeding or enteral nutrition in patients with cirrhosis after bleeding from esophageal varices? A randomized controlled study. Dig Dis Sci 1997;42:536–541. Hebuterne X, Vanbiervliet G. Feeding the patients with upper gastroin - testinal bleeding. Curr Opin Clin Nutr Metab Care 2011;14:197–201. McClave SA, Chang WK. When to feed the patient with gastrointestinal bleeding. Nutr Clin Pract 2005;20:544–550. Naso -gastroenteric tubes are not CI in pts with non-bleeding EV. It is best to avoid PEG insertion in cirrhotic pts because of the risk of bleeding. 78

79. LT PATIENTS After LT initiate normal food and/or enteral tube feeding preferably within 12–24 h postoperatively , or as soon as possible, to reduce infection rates. When oral or enteral nutrition are not possible or are impracticable, parenteral nutrition should be used instead of no feeding in order to reduce complication rates, time on mechanical ventilation and ICU stay. After the acute postoperative phase, provide an energy intake of 35 kcal/kg.BW/d and a protein intake of 1.5 g/ kg.BW/d . Consider parenteral nutrition in pts with unprotected airways and HE when cough and swallow reflexes are compromised, or enteral nutrition is CI or impractical. 79

80. LT PATIENTS Magnesium levels need to be monitored in order to detect and treat cyclosporine or tacrolimus induced hypomagnesaemia . The simultaneous administration of enteral feeding with tacrolimus did not interfere with tacrolimus absorption . Long-term survivors of LT are at considerable risk of becoming overweight or even obese and developing relevant morbidities due to the metabolic syndrome. Attention should be paid to avoiding sarcopenic obesity , using stringent postoperative physiotherapy and dietary counselling. 80

81. Nutritional RX options in LC pts with bone diseases ‘ Hepatic osteodystrophy ’, including osteoporosis and osteomalacia , has been used for years to describe the bone disease of pts with liver damage. Osteoporosis , characterised by loss of bone mass and quality that leads to fragility fractures, is common in pts with CLD.[1] Osteomalacia resulting from poor bone mineralisation is uncommon and only present when a/with persistent vitamin D deficiency in individuals with severe and long-lasting cholestasis and intestinal malabsorption .[2] Guanabens N, Pares A. Liver and bone. Arch Biochem Biophys 2010;503:84–94. Compston JE. Hepatic osteodystrophy: vitamin D metabolism in patients with liver disease. Gut 1986;27:1073–1090 About 30% of pts with CLD have osteoporosis, with higher prevalence in pts with cholestasis including PBC and PSC. 81

82. Nutritional RX options in LC pts with bone diseases Nutritional, hormonal, metabolic, genetic, and inflammatory factors play a significant role in the pathogenesis of osteoporosis in pts with CLD, mainly because of decreased bone formation. The DX of osteoporosis is based on bone mineral density (BMD) that is generally measured by DEXA. According to WHO, osteoporosis is considered when BMD is 2.5 SD below the young average value (T-score ≤2.5) and osteopenia when the T-score is between 1 and 2.5 , and severe or ‘ established’ osteoporosis refers to individuals who meet densitometric criteria and have one or more fragility fractures.[1] Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. World Health Organ Tech Rep Ser 1994;843:1–129. 82

83. Bone densitometry: WHOM AND WHEN? Bone densitometry should be evaluated in pts with previous fragility fractures and those treated with corticosteroids and before LT .[1,2] Bone densitometry needs to be assessed in pts with cholestatic diseases or if any of the described RFs are found, and in cirrhotics . In pts within normal BMD, it is advisable to repeat DEXA after two to three years , as is suggested in the non-cirrhotic population. Guanabens N, Cerda D, Monegal A, Pons F, Caballeria L, Peris P, et al. Low bone mass and severity of cholestasis affect fracture risk in patients with primary biliary cirrhosis. Gastroenterology 2010;138:2348–2356. Pares A, Guanabens N. Treatment of bone disorders in liver disease. J Hepatol 2006;45:445–453. 83

84. Diagnosis and MX of bone disease in pts with CLD *Calcium (1,000–1,500 mg/d) and 25(OH)D (400–800 IU/d or 260 l g every two weeks) to preserve normal levels. **According to the severity of liver disease and cholestasis, and in patients taking corticosteroids. ***Depending on additional risk factors. 25(OH)D, 25-hydroxyvitamin D. DEXA; dual-energy X-ray absorptiometry. 84

85. RFs for the development of osteoporosis in CLD 85

86. Bisphosphonates are anti-catabolic drugs which increase bone mass and reduce the incidence of fractures in post- menopausal osteoporosis. Their effects in CLD are not entirely defined, mostly because of the very limited number of studies and small numbers of pts.[1-6] Nonetheless , etidronate, alendronate and ibandronate ↑ bone mass in pts with PBC, resulting in these pts achieving similar bone mass as pts with osteoporosis a/with other causes.[2,5] Guanabens N, Pares A, Monegal A, Peris P, Pons F, Alvarez L, et al. Etidronate versus fluoride for treatment of osteopenia in primary biliary cirrhosis: preliminary results after 2 years. Gastroenterology 1997;113:219–224. Guanabens N, Pares A, Ros I, Alvarez L, Pons F, Caballeria L, et al. Alendronate is more effective than etidronate for increasing bone mass in osteopenic patients with primary biliary cirrhosis. Am J Gastroen - terol 2003;98:2268–2274. Lindor KD, Jorgensen RA, Tiegs RD, Khosla S, Dickson ER. Etidronate for osteoporosis in primary biliary cirrhosis: a randomized trial. J Hepatol 2000;33:878–882. Wolfhagen FH, van Buuren HR, den Ouden JW, Hop WC, van Leeuwen JP, Schalm SW, et al. Cyclical etidronate in the prevention of bone loss in corticosteroid-treated primary biliary cirrhosis. A prospective, controlled pilot study. J Hepatol 1997;26:325–330. Guanabens N, Monegal A, Cerda D, Muxi A, Gifre L, Peris P, et al. Randomized trial comparing monthly ibandronate and weekly alen - dronate for osteoporosis in patients with primary biliary cirrhosis. Hepatology 2013;58:2070–2078. Zein CO, Jorgensen RA, Clarke B, Wenger DE, Keach JC, Angulo P, et al. Alendronate improves bone mineral density in primary biliary cirrho - sis: a randomized placebo-controlled trial. Hepatology 2005;42:762–771. 86

87. Hormonal replacement therapy In pts with liver disease, hormonal replacement therapy was limited for many years as it was considered harmful. Trans-dermal oestrogens prevent bone loss or even ↑ BMD in pts with PBC or autoimmune cirrhosis and in post-menopausal women after LT, with no AEs on the liver. There are no studies assessing the effects of anabolic drugs in liver pts with osteoporosis, but PTH 1–34 is a potential therapy for osteoporosis in these pts as well as denosumab , a human monoclonal IgG antibody that binds to RANKL and inhibits bone resorption. 87

88. Recommendations [EASL] Evaluate BMD in cirrhotic pts and in cholestatic liver diseases, those receiving long-term corticosteroid RX, and before LT. Utilise lumbar and femoral densitometry (DEXA) to DX osteoporosis and osteopenia. Lateral X-rays of dorsal and lumbar spine for DX vertebral fractures. Include supplements of calcium (1,000–1,500 mg/d) and 25(OH)D (400–800 IU/d or 260 lg every two weeks) in pts with T-score below -1.5. Utilise bisphosphonates in cirrhotic pts with osteoporosis and in those waiting for LT. Consider testosterone supplementation and venesection in males with hemochromatosis and hypogonadism. Moreover, bisphosphonates appear to be well tolerated, although it would be reasonable to exercise caution in using the drug in cirrhotics with recent oesophageal banding/sclerotherapy to avoid oesophageal injury. 88

89. EXPERIMENTAL THERAPIES Follistatin , a myostatin antagonist, has been shown to improve skeletal muscle mass in animal studies. Follistatin treated portocaval anastomosis rats had significantly greater weight gain, gastrocnemius muscle size, and ↑ed grip strength.[1,2] IGF-1 increase muscle protein synthesis and is previously reported to improve nitrogen retention in cirrhotic rats as well as reduce myostatin and increase muscle mass.[3] Becker C, Lord SR, Studenski SA, Warden SJ, Fielding RA, Recknor CP, et al. Myostatin antibody (LY2495655) in older weak fallers: a proof-of-concept, randomized, phase 2 trial. Lancet Diabetes Endocrinol 2015;3:948-957. Han HQ, Zhou X, Mitch WE, Goldberg AL. Myostatin/activin pathway antagonism: molecular basis and therapeutic potential. Int J Biochem Cell Biol 2013;45:2333-2347. Picardi A, de Oliveira AC, Muguerza B, Tosar A, Quiroga J, Castilla- Cortázar I, et al. Low doses of insulin-like growth factor-I improve nitrogen retention and food efficiency in rats with early cirrhosis. J Hepatol 1997;26:191-202. 89

90. MELD-sarcopenia Considering that the MELD lacks a nutritional assessment , recent studies have investigated whether modifying the MELD score to include sarcopenia could improve mortality prediction in pts with LC. A study showed that a novel MELD-sarcopenia score , including the MELD score and L3 SMI, is a/with a modest improvement for predicting mortality in pts with LC, c-statistic for 3-mo mortality was 0.68 for MELD and 0.72 for MELD-sarcopenia].[1] However, prospective studies including a large number of pts with cirrhosis are needed prior to the widespread use of sarcopenia alone or in combination with the MELD score as a prognostic factor. Montano- Loza AJ, Meza-Junco J, Prado CM, Baracos V, Sawyer M, Beaumont C, Ma MM, Kneteman N, Myers RP. Inclusion of sarcopenia within MELD (MELD-sarcopenia) and the prediction of mortality in patients with cirrhosis. Hepatology 2013; 58: 1041A 90

91. Conclusion Nutrition in CLD is a rapidly evolving field and the object of growing clinical interest. Nutritional impairment and sarcopenia have been recognised as crucial complications of chronic liver disease, which severely impact on prognosis. Undernutrition and sarcopenia are also interconnected with other complications of cirrhosis such as HE, ascites and the susceptibility to infection. The molecular mechanisms underlying sarcopenia have been investigated in depth and clarified to some extent. At the same time, a novel condition has emerged , i.e. the occurrence of overweight and obesity in cirrhotic pts. This deserves both clinical attention and further study . Recent research has provided preliminary data on the potential benefit of physical activity in pts with cirrhosis. 91

92. END OF SLIDES 92

93. Hypogycemia in LC Generally, the liver plays an important role in glucose metabolism, in terms of glucolysis and gluconeogenesis [1]. The liver functions as a reserve for carbohydrates, storing glycogen from glucose in postprandial periods and releasing glucose during fasting periods [2]. In pts with LC, the capacity of the liver to preserve carbohydrates is impaired [2] and there is impaired gluconeogenesis as well.[3,4] Garcia- Compean D, Jaquez-Quintana JO, Gonzalez-Gonzalez JA, Maldonado- Garza H. Liver cirrhosis and diabetes: risk factors, pathophysiology, clinical implications and management. World J Gastroenterol 2009;15(3):280–8 [ Epub 2009/01/14]. Nishida T, Tsuji S, Tsujii M, Arimitsu S, Haruna Y, Imano E, et al. Oral glucose tolerance test predicts prognosis of patients with liver cirrhosis. Am J Gastroenterol 2006;101(1):70–5 [ Epub 2006/01/13]. Hagel S, Bruns T, Herrmann A, Stallmach A, Schmidt C. Abnormal glucose tolerance: a predictor of 30-day mortality in patients with decompensated liver cirrhosis. Z Gastroenterol 2011;49(3):331–4 [ Epub 2011/03/11]. Kawaguchi T, Taniguchi E, Itou M, Sakata M, Sumie S, Sata M. Insulin resistance and chronic liver disease. World J Hepatol 2011;3(5):99–107 93

94. References: Cardiac Sarcopenia Ortiz-Olvera NX, Castellanos- Pallares G, Gomez-Jimenez LM, Cabrera-Munoz ML, Mendez-Navarro J, Moran- Villota S, Dehesa-Violante M. Anatomical cardiac alterations in liver cirrhosis: an autopsy study. Ann Hepatol 2011;10:321-326. Liu H, Lee SS. Acute-on-chronic liver failure: the heart and systemic hemodynamics. Curr Opin Crit Care 2011;17:190-194. Moller S, Henriksen JH. Cirrhotic cardiomyopathy. J Hepatol 2010;53:179-190. Timoh T, Protano MA, Wagman G, Bloom M, Vittorio TJ. A perspective on cirrhotic cardiomyopathy. Transplant Proc 2011;43:1649-1653. Dec GW, Kondo N, Farrell ML, Dienstag J, Cosimi AB, Semigran MJ. Cardiovascular complications following liver transplantation. Clin Transplant 1995;9:463-471. Johnston SD, Morris JK, Cramb R, Gunson BK, Neuberger J. Cardiovascular morbidity and mortality after orthotopic liver transplantation. Transplantation 2002;73:901-906. Therapondos G, Flapan AD, Plevris JN, Hayes PC. Cardiac morbidity and mortality related to orthotopic liver transplantation. Liver Transpl 2004;10:1441-1453. Pruthi J, Medkiff KA, Esrason KT, Donovan JA, Yoshida EM, Erb SR, Steinbrecher UP, et al. Analysis of causes of death in liver transplant recipients who survived more than 3 years. Liver Transpl 2001;7:811-815. Neuberger J. Liver transplantation. J Hepatol 2000;32:198-207. 2015 american transplant congress abstracts. Am J Transplant 2015;15 Suppl 3:S1. Mathew A, Halegoua -De Marzio D, Reddy S, Wong SY, Cheung M, Mosca H, Guglielmo F, et al. Pre-Liver Transplant Muscle Loss Is a Risk Factor for Post-Liver Transplantation Left Ventricular Systolic Dysfunction. Ann Transplant 2017;22:759-764. 66th annual meeting. American association for the study of liver diseases: liver meeting 2015. Hepatology 2015;62. 94

95. Skeletal muscle fiber types Skeletal muscle consists of four fiber types (Type I, IIa , IIb and IIx ) that differ with regards to functionality and how rapidly they are exhausted.[1] Type I: slow twitch fibers , are red due to the presence of significant amount of myoglobin, and are resistant to exhaustion and are capable of producing repeated low-level contractions by producing large amounts of ATP through an aerobic metabolic cycle . Muscles containing mainly type I fibers are often postural muscles (neck and spine) . Type IIa : fast oxidative fibers , have a large amount of mitochondria and myoglobin. They create and split ATP at a fast rate by utilizing both aerobic and anaerobic metabolism , consequently generating faster, and stronger contractions. Type Iib : fast glycolytic fibers , are white due to a lower level of myoglobin, and they produce ATP at a slow rate by anaerobic metabolism and break it down very rapidly. Finally, type IIx fibers contain very few mitochondria, and derive ATP from anaerobic metabolism and have a high glycolytic capacity and fatigue quickly.[1] Type II fibers are more sensitive to disease states as they are unable to counteract the upregulatation of ubiquitin in these states.[2] Thus, it is the preferential loss of fast twitch fibers that is expected to occur in cirrhosis and other chronic diseases.[3] Curry JW, Hohl R, Noakes TD, Kohn TA. High oxidative capacity and type IIx fibre content in springbok and fallow deer skeletal muscle suggest fast sprinters with a resistance to fatigue. J Exp Biol 2012;215:3997-4005. Schiaffino S, Reggiani C. Fiber types in mammalian skeletal muscles. Physiol Rev 2011;91:1447-1531. Dasarathy S, Merli M. Sarcopenia from mechanism to diagnosis and treatment in liver disease. J Hepatol 2016;65:1232-1244. 95