Malnutrition is a common condition encountered in patients with inflammatory bowel disease (IBD) and is often associated with sarcopenia (the reduction of muscle mass and strength) which is an ever-growing consideration in chronic diseases. Recent data suggest the prevalence of sarcopenia is 52% and 37% in Crohn’s disease and ulcerative colitis, respectively, however it is challenging to fully appreciate the prevalence of sarcopenia in IBD. Sarcopenia is an important consideration in the management of IBD, including the impact on quality of life, prognostication, and treatment such as surgical interventions, biologics and immunomodulators. There is evolving research in many chronic inflammatory states, such as chronic liver disease and rheumatoid arthritis, whereby interventions have begun to be developed to counteract sarcopenia. The purpose of this review is to evaluate the current literature regarding the impact of sarcopenia in the management of IBD, from mechanistic drivers through to assessment and management.

Patients with liver cirrhosis and, in particular, those with liver failure are at high risk of reduced muscle mass and strength/function, otherwise known as sarcopenia. Sarcopenia is a complex, multifactorial (poor nutritional intake, protein catabolism, physical inactivity) chronic condition, which increases the risk of liver-related morbidity and mortality. Early recognition and tailored management incorporating high protein diets and combination aerobic/resistance exercise can ameliorate the complications associated with sarcopenia in cirrhosis. This review provides an overview of the epidemiology, pathogenesis, assessment tools and management of sarcopenia in cirrhosis.

The exponential rise in obesity and prevalence of alcohol misuse has resulted in liver disease becoming the third most common cause of death in the working-age population.1 A key aspect of managing patients with liver disease, from the stages of compensated cirrhosis through to liver failure, is early recognition and treatment of malnutrition. Malnutrition is defined as a deficiency or excess (or imbalance) of energy, protein and other nutrients and is most often associated with undernutrition.2 3 In cirrhosis, this is closely associated with a reduction in muscle mass, function and strength, known as sarcopenia.4 Collectively, malnutrition and sarcopenia negatively impact on a patients’ ability to complete daily tasks, quality of life, liver-related morbidity and mortality.1 5–10 Given the increasing prevalence of obesity, diabetes and their association with non-alcoholic fatty liver disease (NAFLD), an imbalance of nutritional intake is becoming increasingly observed in patients with cirrhosis.11 12 The resultant combination of adiposity and sarcopenia, termed ‘sarcopenic obesity’, poses unique nutritional challenges, with regard to optimising metabolic risk factors (ie, weight loss, glycaemic/lipid control) and muscle function.

Background: Several chronic inflammatory diseases co-exist with and accelerate sarcopenia (reduction in muscle strength, function and mass) and negatively impact on both morbidity and mortality. There is currently limited research on the extent of sarcopenia in such conditions, how to accurately assess it and whether there are generic or disease-specific mechanisms driving sarcopenia. Therefore, this study aims to identify potential mechanisms driving sarcopenia within chronic inflammatory disease via a multi-modal approach; in an attempt to help define potential interventions for future use. Methods: This prospective cohort study will consist of a multi-modal assessment of sarcopenia and its underlying mechanisms. Recruitment will target three chronic inflammatory diseases: chronic liver disease (CLD) (n=50), with a subset of NAFLD (n=20), inflammatory bowel disease (IBD) (n=50) and rheumatoid arthritis (RA) (n=50) both before and after therapeutic intervention. In addition, 20 age and sex matched healthy individuals will be recruited for comparison. Participants will undergo 4 assessment visits at weeks 0, 2, 12 and 24. Visits will consist of the following assessments: blood tests, anthropometrics, functional assessment, quadriceps muscle imaging, actigraphy, quality of life questionnaires, food diary collection and muscle biopsy of the vastus lateralis (at weeks 2 and 24 only). In addition, stool and urine samples will be collected for future microbiome and metabolomics analysis. Discussion: This is the first study to use a multi-modal assessment model to phenotype sarcopenia in these chronic inflammatory diseases. We hope to identify generic as well as disease-specific mechanisms driving sarcopenia. We appreciate that these cohorts do require separate standards of care treatments which limit comparison between groups. Ethics and dissemination: The study is approved by the Health Research Authority - West Midlands Solihull Research Ethics Service Committee Authority (REC reference: 18/WM/0167). Recruitment commenced in January 2019 and will continue until July 2021. The study was halted in March 2020 and again in January 2021 with the COVID-19 pandemic. The findings will be disseminated through peer-reviewed publications and conference presentations. All data will be stored on a secure server. Trial registration: ClinicalTrials.gov Identifier: NCT04734496

Patients who undergo solid organ transplantation are at risk of opportunistic infection associated with immunosuppression. We report a case of confirmed donor derived visceral leishmaniasis (VL), in a patient following liver transplantation causing fever and pancytopenia. The diagnosis was confirmed by bone marrow biopsy, with confirmed positive donor serology, with no other route of transmission. To our knowledge, this is the first case report in the United Kingdom and Europe, of confirmed organ donor transmission of VL. This case report highlights an important consideration of donor derived infections, in the context of solid organ transplantation.

Introduction End stage liver disease (ESLD) negatively impacts muscle homeostasis with observed reductions in muscle mass (sarcopenia) and strength. The current recommended measures of muscle mass in ESLD are 3rd lumbar vertebral skeletal muscle index (L3 SMI) via CT/MRI and/or the by-the-bedside mid arm muscle circumference (MAMC). However, little is known how well these represent muscle mass and strength in the lower limbs. The aim of this prospective study was to understand how well conventional measures of sarcopenia correlate with measures of lower limb muscle mass and strength in patients with ESLD. Methods Patients with ESLD underwent: MRI imaging of the trunk (conventional L3 SMI (cm3/m2) and lower limb (quadriceps volume (cm3), quadriceps volume index (cm3/m2), peak quadriceps anatomical cross-sectional area (ACSA (cm2)); ultrasound measured vastus lateralis muscle thickness (cm); MAMC (cm); peak dominant handgrip strength (HGS (kg)), maximal isokinetic leg extension peak torque (Nm) using dynamometry and habitual physical activity via accelerometry. Results In total 39/42 patients with ESLD cohort (62% male; mean age 55 yrs; MELD 13; Child Pugh 8; ArLD 48%) provided a full dataset. L3 SMI was positively correlated with all lower limb MRI measures of muscle mass (r=0.64–0.68, p<0.01) and ultrasound (R=0.42, p<0.05). L3 SMI correlated with both leg extension peak torque (r = 0.57; p<0.001) and HGS (r = 0.43, p<0.05). All MRI measures of lower limb muscle mass were significantly correlated with measures of lower and upper limb strength (figure 1). Of all modalities, MRI measured quadriceps volume had the strongest correlation with both upper (HGS r= 0.60, p<0.001) and lower limb muscle strength (leg extensor peak torque r= 0.71, p<0.001). MAMC, however, correlated poorly with L3 SMI and all measures of strength, including HGS (r=0.03, p=ns) Correlation matrix for all measures of muscle mass, strength and performance. P values denoted by *p<0.05, **p<0.01, ***p<0.001. Conclusion Unlike MAMC, the conventional use of L3 SMI is an adequate surrogate marker for both lower limb muscle mass and strength. Overall, MRI quadricep volume demonstrated the strongest relationship with both upper and lower limb muscle wasting and weakness. Our findings suggest MRI quadricep volume may be a more suitable assessment tool for muscle compromise in ESLD.