肝硬変・肝細胞がんとサルコペニア

しばらくは
Abstracts of the 6th Cachexia Conference, Milan, Italy, December 8–10, 2011. J Cachexia Sarcopenia Muscle DOI 10.1007/s13539-011-0045-3
からの紹介を続けます。

肝硬変で肝細胞がんのある患者とない患者のサルコペニアに関するコホート研究を紹介します。
Judith Meza-Junco, et al: Sarcopenia in cirrhotic patients with and without hepatocellular carcinoma

筋肉量に関してはL3レベルのCTで評価しています。163人の肝硬変患者のうち、51人（31％）が肝細胞がんあり、112人（69％）が肝細胞がんなしです。平均年齢55歳、男性118人、女性45人。フォローアップ期間の中央値は19カ月。サルコペニアは61人（37％）に認めましたが、肝細胞がんの有無による有意差は認めませんでした。

多変量解析で死亡率と有意に関連していたのは、Model for End-Stage Liver Disease（MELD）とサルコペニアだけでした。また、サルコペニアとMELD、Child–Pugh得点には有意な関連を認めませんでした。

MELDスコアとは、プロトロンビン時間（PT−INR）、血清クレアチニン値、直接ビリルビン値で下記の式より計算されます。肝硬変患者の短期の予後予測に優れているそうです。
MELD score=3.8log e （bilirubin [mg/dL]）+11.2log e （INR）+9.6log e （creatinine [mg/dl]+6.4 （etiology: 0 if cholestatic or alcoholic, 1 othewise）

結論として、肝硬変患者の37％にサルコペニアを認め、サルコペニアは独立した死亡の予測因子であり、肝機能障害スコアとは関連していませんでした。

肝硬変患者でサルコペニアや悪液質の評価が重要なのは確かです。日本ではもっと多い印象があります。サルコペニアの原因が悪液質なのか、その他なのか、どのように介入すれば肝硬変患者でも筋肉量・筋力を増やすことができるのか、が今後の研究課題かと思います。
Background/aims: Prognostic assessment of cirrhotic patients remains a
challenge. Sarcopenia is defined as low levels of muscle mass; it may be
present in chronic/malignant diseases. It is not well-studied/understood in
cirrhotic and HCC patients. We aimed to establish sarcopenia frequency
and if it predicts mortality in a cohort of cirrhotic patients with and without
hepatocellular carcinoma (HCC).

Patients and methods: One hundred sixty-three patients with cirrhosis
were consecutively evaluated for liver transplant and had computed
tomography (CT) scan at the third lumbar vertebrae were selected. Skeletal
muscle cross-sectional area was measured by CT to determine the third
lumbar vertebrae (L3) skeletal muscle index (L3 SMI) defined as total
lumbar muscle cross-sectional area adjusted for stature; sarcopenia was
defined using previously published gender-specific cutoffs.

Results: One hundred eighteen patients were males (72%), mean age of 55
±1 years, 51 patients (31%) had HCC at the time of CT. Median time of
follow-up was 19±1 months. Sarcopenia was present in 61 patients (37%),
and there was no difference in the frequency of sarcopenia among patients
with and without HCC (31% vs. 40%, P=0.3). By univariate Cox analysis
the bilirubin, creatinine, albumin, Model for End-Stage Liver Disease
(MELD), Child–Pugh, sodium, L3 SMI, and sarcopenia were associated
with mortality. The presence of HCC was not associated with increased
mortality (HR 1.12, P=0.6). By multivariate Cox regression analysis, only
MELD score (HR 1.08, P=0.001), and sarcopenia (HR 2.18, P=0.001)
were independently associated with early mortality. Median survival for
sarcopenic patients was 19±5 months, compared to 30±2 months in
nonsarcopenic patients (P=0.001). There was a poor correlation
between sarcopenia and MELD score (r=−0.13, P=0.1) and sarcopenia
and Child–Pugh score (r=0.04, P=0.6).

Conclusions: Sarcopenia is present in 37% of patients with cirrhosis
and is not associated with the presence of HCC. Sarcopenia
constitutes a strong and independent predictor of mortality in cirrhotic
patients and does not correlate with degree of liver dysfunction
evaluated with conventional scoring systems. Further studies including
sarcopenia with conventional scores may allow better mortality
prediction among cirrhotic patients with and without HCC.