Methods
This was a cross sectional study conducted in the outpatient medicine clinic of Aga Khan University hospital Karachi (AKUH) and Jinnah postgraduate medical center (JPMC) Karachi. All patients aged ≥ 14 years, with either history of viral CLD (HBsAg or HCV) or non-viral CLD who had established diagnosis of liver cirrhosis of any etiology were recruited in the study after obtaining the informed consent. Consent from parent or guardian was taken for those who were minors. Liver cirrhosis was diagnosed based on ultra-sonographic evidence of chronic liver disease including shrunken liver, dilated portal vein, splenomegaly. We used nonrandom purposive technique for recruiting participants in this study [13, 14].
Study measurements included demographic information, measurement of anthropometric measures, history of decompensation (including upper gastrointestinal bleed, ascites, and portosystemic encephalopathy) biological specimens (urine and blood) and assessment of total body water and fat free mass using BIA.
Anthropometry
Height was measured with portable stadiometer to the nearest of 0.1 cm and mean of three readings were documented. Triceps skin fold thickness was measured with a Lange caliper [15]. Mid arm circumference was calculated from the right arm at mid-point equidistant from the acromion and olecranon, with the patient in the upright position and arm flexed at 90°. The arm muscle circumference was calculated by the following formula using MAMC = MAC − (TSF × 0.3142). Reference for MAMC was obtained from Indian study [16, 17]. Weight was measured on Tanita weighing scale to the nearest of 0.1 kg. Biological specimen including albumin, creatinine, lymphocyte and 24 h urinary creatinine was measured using ADVIA 1800 in the lab. Malnutrition was assessed by using the following formula for PCM score [18]
$${\text{PCM}} = \frac{{\% \;{\text{TCF}} + \% \;{\text{MAC}} + \% \;{\text{MAMC}} + \% \;{\text{lymphocyte}} + \% \;{\text{albumin}} + \% \;{\text{CHI}}}}{6}$$
where TCF is triceps skin fold, MAC is mid arm circumference, MAMC is arm muscle circumference. Percent TCF % MAC, % MAMC, % lymphocyte, % albumin and % CHI were calculated as percent of the normal values. These normal values from a healthy Indian population were; mean TCF = 12 cm, mean MAMC = 26 cm) were used for the above percent calculation [17]. Malnutrition was classified based on this score as, mild (99.9–80%), moderate (60–79.9%) and severe (< 60%) according to the recommendation by Blackburn et al. [19, 20]. PCM score for this study was considered as gold standard.
Bioelectrical impedance measurement
BIA was performed using a BIA 2000M (Data Input GmbH, Darmstadt, Germany) [21] applying alternating current of 800 micro amperes at 50 kHz in the clinic. BIA was measured in the supine position with arm and legs abducted from the body in the morning after an overnight fast. The two electrodes (one for sensor and other for source) were placed on the dorsum of both hand foot of the dominant side of the body. Resistance (R), reactance (Xc) and the phase angle (alpha) was measured at each frequency. All impedance measurements were taken with the patient supine, arms relaxed at the sides but not touching the body. Total body water (TBW) and fat free mass [22] was calculated by using formula by Kushner and Schoeller [23]. Body cell mass was calculated by the formula; BCM = F.F.M * 0.29 * LN(5.28). This was used for assessment in cirrhotic young adults [7]. Body cell mass should be at least 40% of the body weight for a person to be designated as not malnourished [24].
