Use of temporal muscle thickness measured by ultrasonography in the assessment of nutritional status in patients with liver cirrhosi̇s

Introduction and Aim: Malnutrition is common in patients with cirrhosis. It is a serious health problem that increases the morbidity and mortality of patients. Various laboratory data, scoring systems and anthropometric measurements are used in the evaluation of malnutrition in patients with cirrhosis. However, these measurements take time, it is a problem to reach a clear result and cannot reveal the malnutrition rate alone. Some recent studies support that reduction in temporal muscle mass may be associated with malnutrition rate. In our study, we used temporal muscle thickness (TMT) measured by ultrasonography as a parameter for early detection of malnutrition in patients with cirrhosis. We aimed to confirm the validity and reliability of TMT alone to determine nutritional status and to investigate whether it is significantly associated with nutritional status. Materials and Methods: A total of 85 individuals, 65 patients with a mean age of 65 years and 20 healthy controls with a mean age of 59.5 were examined. Our research is a cross-sectional study. Demographic data of the patients (age, gender, primary etiology of cirrhosis) and laboratory parameters (serum albumin, total bilirubin, INR, ALT, AST, white blood cell, hemoglobin, neutrophil, lymphocyte, thrombocyte), routine outpatient examinations of the patients and data during hospitalization. The files were analyzed retrospectively. Anthropometric measurements (dry weight, body mass index, triceps skinfold thickness(TST), temporal muscle thickness) were calculated. Child Turcotte Pugh (CTP), The Royal Free Hospital- Nutritional Prioritizing Tool (RFH-NPT) Evaluation scores were applied to the patients by a single physician, and TMT was measured by a single physician by ultrasonography. Malnutrition classification was made according to TST measurement and anthropometric measurements, TKK values of the patients were compared. Results: Within the scope of the study, a total of 85 individuals, 65 of whom were patients with cirrhosis (median age: 65 years) and 20 of whom were healthy controls (median age: 59.5 years), were examined. The medians of the right and left TMT of the patients were 9.2mm and 9.3mm, respectively. A statistically significant difference was found between the patient and control groups in terms of age, body weight, body mass index (BMI) and obesity status (respectively; p<0.001; p=0.003; p<0.001; p=0.002). There was no statistically significant difference between the patient and control groups in terms of gender and height (p>0.05). TST, right and left TMT values of the patients were significantly lower than the healthy individuals in the control group (respectively; p<0.001; p=0.001; p=0.001). While the etiology of 29.2% of cirrhosis patients examined within the scope of the study was cryptogenic, it was followed by NASH with 16.9%, Hepatitis-B with 15.4%, cardiac causes with 13.9% and Hepatitis-C with 10.8%. The least detected etiology was cirrhosis due to Hepatitis-B and Hepatitis-C coinfection with 1.5%. The patients were divided into two groups according to the RPH-NPT score as those with low/intermediate risk malnutrition (n=45) and those with high risk malnutrition (n=20). The median RPH-NPT score of the patients was 1 (IQR:0-2) and the malnutrition risk was low in 49.2%, moderate in 20.0% and high in 30.8%. While 38.4% of the patients were CTP class A, 30.8% were B and the remaining 30.8% were C. While ascites was not detected in 43.1% of patients with cirrhosis, mild acid was detected in 16.9% and severe acid in 40.0%. While encephalopathy was absent in 67.7% of the patients, moderate encephalopathy was present in 23.1% and severe in 9.2%. The age of patients with cirrhosis with high risk of malnutrition was found to be significantly higher than those of low/intermediate risk patients, and BMI was found to be significantly lower (p=0.013, p=0.021). In the correlation analysis, the right and left TMT values of patients with cirrhosis and age, NLR and RPH-NPT values were found to be negative, moderate; a positive, moderate, statistically significant relationship was found between BMI and serum albumin values. The diagnostic decision-making properties of the right and left TMT values in predicting high-risk malnutrition were evaluated by ROC curve analysis. Accordingly, both the right (AUC: 0.696, 95% CI: 0.39-0.69) and left TMT (AUC: 0.691, 95% CI: 0.55-0.83) were found to be diagnostic-determining features in predicting high-risk xvii manipulation (p<0.05). ). According to the cut-off value of 9.05 mm determined for the right TMT; while the sensitivity was 70%, specificity 62.2%, positive predictive value 17.6% and negative predictive value 54.8% in predicting high degree of malnutrition; according to the 9.05 mm cut-off value determined for left TMT, the sensitivity was 65%, specificity 68.9%, positive predictive value 18.4% and the negative predictive value was 51.9%. While NLR values of patients with high malnutrition risk level were significantly higher than those of low/intermediate risk patients, serum albumin values were significantly lower (p<0.05). When the median NLR value of 2.58 was taken as cut-off, the percentage of patients with high risk of malnutrition among patients with cirrhosis with an NLR value of 2.58 and above was found to be significantly higher than those with an NLR value of less than 2.58 (p<0.05). The right and left temporal muscle thicknesses of patients with cirrhosis with an NLR value of 2.58 and above were significantly lower than those with an NLR value below 2.58 (respectively; p=0.016; p=0.012). There was no statistically significant difference between patients' NLR levels in terms of triceps skinfold thickness (p>0.05). Conclusion: The TMT value measured by ultrasonography is diagnostic in predicting high-risk malnutrition in patients with chronic cirrhosis. We suggest that TMT measured by ultrasonography, which is a noninvasive, simple and objective evaluation method, should be used for the diagnosis of malnutrition in patients with cirrhosis. Keywords: Malnutrition, Cirrhosis, Temporal muscle thickness