Gut liver muscle brain axis: A comprehensive viewpoint on prognosis in cirrhosis

Gut liver muscle brain axis: A comprehensive viewpoint on prognosis in cirrhosisTo the Editor:We read with interest the paper by Tantai et al. in which the authors conclude that sarcopenia was highly and independently associated with a higher risk of mortality in patients with cirrhosis. 1irrhosis is a well-known devasting disease with a heavy social and healthcare burden.Mortality in patients suffering from advanced liver disease is higher if the course of disease is complicated by clinically significant portal hypertension.The model for end-stage liver disease (MELD) score is widely used to assess the severity of liver disease, its mortality and to help prioritise patients for liver transplantation.In recent years, the relationship between muscular alterations and hepatic encephalopathy (HE) has been deeply studied.The pathophysiological background supporting the relationship between muscle depletion and HE starts from the involvement of muscle in ammonia metabolism and trafficking.Ammonia plays a central role in the pathogenesis of cognitive impairment in cirrhosis, being increased because of the inability of the liver to remove ammonia through urea synthesis due to liver failure and/or the presence of porto-systemic shunts.Skeletal muscle may play a compensatory role in ammonia clearance through glutaminesynthase, which metabolizes ammonia into glutamine.Consequently, muscle depletion may favour ammonia accumulation and finally HE development. 2We recently described the relationship between muscular alterations and HE, both minimal and overt. 3In the same study, survival was significantly lower in malnourished patients compared to patients without sarcopenia.Moreover, the accuracy of MELD in predicting 3-and 6-month mortality may be improved by considering muscular alterations.Indeed, a model considering the above parameters may more accurately classify over 30% of patients. 4Therefore, HE and muscle alterations could be used to improve the determination of prognosis in patients with cirrhosis.Herein, we report some data on patients with cirrhosis prospectively followed by our unit, in which a comprehensive assessment of liver disease as well as of mental status has been performed.The presence of sarcopenia was evaluated accordingly to skeletal muscle index obtained by CT scan.Occurrence of HE episodes and mortality have also been recorded.One hundred and fifty one patients with cirrhosis (M/F 107/ 44), age 59.5±11.6 years, with a prevalence of viral aetiology (75/ 50%) were followed up for a mean period of 12.7±10.1 months.Severity of cirrhosis was evaluated by Child-Pugh Class (A/B/C: 40/80/31) and MELD score (13.8±5).Sarcopenia was present in 84 patients (56%) and previous history of HE in 51 (34%) patients.Death occurred in 59 (39%) patients during follow-up, while overt HE occurred in 53 (35%) of patients.The presence of sarcopenia (29% vs. 7%, p <0.001), previous HE (28% vs. 6%, p <0.001), or HE during follow-up (25% vs. 9%, p = 0.005) were associated