Association between malnutrition determined by hand grip strength and the presence of minimal hepatic encephalopathy in women with liver cirrhosis

Introduction and Objectives

Minimal hepatic encephalopathy (MHE) represents the initial stage within the spectrum of hepatic encephalopathy (HE). Its presence has been linked to muscular alterations: a reduction in the Skeletal Muscle Index was observed in 84% of MHE patients. Moreover, between 41-49% of individuals with MHE exhibit muscle depletion, as indicated by their mid-arm muscle circumference (MAMC) falling below the 5th percentile. Hand grip strength (HGS) serves as a marker of muscle functionality; however, the relationship between HGS values and the presence of MHE remains uncertain. Therefore, this study aims to achieve two primary objectives: 1) to establish a cut-off value for classifying malnutrition based on HGS measurements and 2) to investigate the association between malnutrition, as determined by HGS and the presence of MHE.

Materials and Patients

This cross-sectional study enrolled 241 female participants from the Gastroenterology department at Hospital de Especialidades of Centro Médico Nacional Siglo XXI. Eligible participants were aged between 18 and 76 years and diagnosed with liver cirrhosis of any etiology, excluding cases related to excessive alcohol consumption. Exclusion criteria included recent antibiotic use (<1 month), chronic kidney disease, elevated creatinine levels, hepatocellular carcinoma, illiteracy, and a history of hepatic encephalopathy (HE) or current decompensation due to variceal hemorrhage. Various parameters, including chronometric, clinical, biochemical, anthropometric, and dietary factors, were assessed. The determination of the malnutrition cut-off point based on hand grip strength was established using tertiles, and the association between these values and Minimal Hepatic Encephalopathy (MHE) was evaluated through logistic regression analysis. Statistical calculations were performed using the SPSS© 27 software.

Results

The median age of the participants was 59 years (interquartile range 52-63). Among subjects, 168/241 (50.8%) individuals with liver cirrhosis had hepatitis C virus as an associated factor, while 136/241 (56.4%) were classified as stage 2 cirrhosis, and 37/241 (15.4%) presented with ascites. Furthermore, 36/ 241 (14.9%) participants were diagnosed with MHE. The threshold for identifying malnutrition based on HGS was established as the values falling within the lowest tertile of the sample (<16.5 kg), resulting in 76/241 (31.5%) individuals being classified as malnourished. Malnutrition showed an association with the presence of MHE, OR: 2.214 (95% CI: 1.077-4.552, p=0.031). Adjustment of models for the presence of hyponatremia, BMI, CAMB, triceps skinfold, and Child-Pugh score did not alter this association. However, when accounting for albumin levels (g/dl), both malnutrition and albumin levels were independently associated with the presence of MHE [Malnutrition OR: 2.104, 95% CI 1.014-4.364, p=0.046 / Albumin OR: 0.512, 95% CI 0.282-0.932, p=0.028].

Conclusions

Reduction of the hand grip is associated with an increased risk of MHE, supporting the role of muscle tissue in the development of MHE.

Ethical Statement: Approval for the study was obtained from the local ethics committee (R-2024-3601-045).

Declaration of Interests: None.

Financing: This study received partial funding from project No. SALUD-2014-1-233823 of CONACyT (National Council of Science and Technology).