Keywords sarcopenia - liver cirrhosis - exercise - branched-chain amino acid - smartphone application
Schlüsselwörter Sarkopenie - Leberzirrhose - Bewegung - verzweigtkettige Aminosäure - Smartphone-Anwendung
Introduction
Sarcopenia, characterized by generalized loss of skeletal muscle volume and strength,
is a
major element of malnutrition in liver cirrhosis (LC). Sarcopenia and pre-sarcopenia
were
found not to be rare even in patients with chronic liver disease (CLD), including
those in
early stages [1 ]. The annual rates of skeletal muscle volume loss were 1.3%, 3.5%, and 6.1% for
patients with Child–Pugh class A, B, and C, respectively [2 ]. The importance of sarcopenia or pre-sarcopenia is that it’s associated with not
only
reduced quality of life, but also increased decompensation event frequency and prolonged
hospitalization, affecting the overall prognosis of cirrhosis [3 ]. For patients with cirrhosis, early diagnosis and appropriate treatment for sarcopenia
are important. Although the clinical significance of sarcopenia in cirrhosis has been
widely
recognized, effective therapies are still to be discovered [4 ]. Reported strategies for treating sarcopenia related to cirrhosis include exercise
regiments and supplementation with branched-chain amino acid (BCAA) [5 ]
[6 ]. Previous studies have shown the superiority of exercise combined with BCAA
supplementation in improving muscle mass, muscle strength, and physical function [1 ]
[7 ]
[8 ]
[9 ]. However, most of them used pre-post-intervention study design and few emphasized
comparison of interventions administrated combined or separately. Whether the combined
intervention was more beneficial is still unknown.
Furthermore, traditional supervised exercise was mainly engaged in by professionals,
resulting in high cost [10 ]. The specified repetitive content or form of supervised exercise also makes it
difficult to develop an exercise habit or keep on once the intervention has stopped.
As most
patients in the early stage of LC don’t need to be in hospital for a long time, long-term
effects of interventions should be of concern. Rapidly expanding availability of smartphones
provides a way to deploy interventions in a simple mode. WeChat (the Chinese version
is
WeiXin), like Facebook in the USA, as a representative form of modern messaging software,
is
widely used in China. We could easily record the routine activities such as daily
steps
through the “WeRun” modular. It has been demonstrated that using the WeChat application
for a
follow-up visit was time-effective, cost-effective, and convenient [11 ]. It may also help make an exercise habit in the patients’ community life that would
work for a long time. Nevertheless, a recent study reported high acceptance but low
usage of
smartphone applications for the management of cirrhosis [12 ].
We hypothesized that unsupervised exercise using WeChat combined with BCAA supplementation
would benefit loss of muscle volume and strength in cirrhosis. The purpose of this
study is to
investigate the effects of walking exercise using WeChat combined with BCAA supplementation
on
skeletal muscle mass and muscle strength in LC patients.
Materials and Methods
Patients
This study was an open-label prospective study. LC patients of Child–Pugh class A/B
were
recruited from June 2020 to May 2021 at the Sixth People’s Hospital of Chengdu (Chengdu,
Sichuan Province, China). Diagnosis of cirrhosis were based on the Chinese guideline
for
diagnosis and treatment of LC [13 ]. They were assigned to three groups according to the patients’ personal desires:
Group A, patients with oral BCAA supplements; Group B, patients with walking exercise
(additional 2000 steps/day); and Group C, those who received both BCAA supplements
and
walking exercise. The leading inclusion criteria were as follows: 1) age ≥18 years,
and 2)
presence of cirrhosis based on medical history, physical examination, laboratory tests,
or
portal hypertension features from ultrasound or endoscopy. Patients of Child–Pugh
C or those
with refractory ascites might be difficult in dietary intake or walking. Thus, the
exclusion
criteria were as follows: 1) Child–Pugh class C; 2) uncontrolled ascites; 3) other
disease
conditions such as diabetes mellitus, coronary heart disease, pulmonary edema, or
chronic
kidney disease; 4) malignant tumors including hepatocellular carcinoma; 5) BCAA
supplementation within 6 months before the date of entry; and 6) systemic bodybuilding
within 6 months before the date of entry.
Study Protocol
Sample size for each group was calculated to be n=29.6 with the problem probability
set
to 0.15 and the confidence level set to 95% according to previous studies. Of the
238 adult
patients with LC, 111 patients were excluded, and 127 patients were included on the
basis of
the above criteria. The 127 participants were assigned to group A (n=42), group B
(n=43),
and group C (n=42) after enrollment ([Fig. 1 ]). Participants in every group underwent conventional health education and physical
and laboratory examinations, which included serum BCAA, skeletal muscle mass index
(SMI),
and grip strength. Average daily steps were calculated via smartphone app (WeChat,
Tencent
Corporation, China) for 2–3 weeks. Then patients in group A received oral BCAA
supplementation (CLEAR BCAA, protein 8.9 g, including L-leucine 3000 mg, L-isoleucine
750
mg, L-valine 750 mg; 159 kcal/day; Nortland Biotechnology Co. Ltd, China) as a late
evening
snack. Time and amount of amino acid they took every day were collected by a research
assistant through the WeChat application to monitor the BCAA intake accurately. Patients
in
group B were prescribed walking exercise for an additional 2000 steps/day. Data of
daily
steps and heart rates were recorded through a smart bracelet interconnected with the
WeChat
application in the WeRun model, then sent manually to research assistants in the form
of
screenshots by the patients themselves before going to sleep every night. Research
assistants would send exercise tips and answer questions from participants via WeChat
message to help achieve exercise goals. Patients were informed that heart rates should
not
exceed 60% of the maximum heart rate during walking. Participants in group C received
both
interventions for 3 months. Information security and privacy protection clauses of
WeChat
met the ISO/IEC 27701:2019 standard certification. Strict compliance with information
security and privacy protection were taken during the whole study process.
Fig. 1 Flow chart of participant selection.
Laboratory methods
Laboratory data (alanine aminotransferase (ALT), aspartate aminotransferase (AST),
alkaline phosphatase (ALP), albumin, total bilirubin, prothrombin time, BCAA) were
analyzed
at enrollment, as well as 1, 2, and 3 months after starting the nutrition supplementation
or
exercise protocol. A blood test of BCAA was accomplished by the Clinical Laboratory
Center
of the Sixth People’s Hospital of Chengdu through the colorimetric method, the testing
kit
provided by Sigma-Aldrich Life Science & Tech. Co., Ltd., Wuxi, China.
Measures of SMI and grip strength
A computerized tomography scan was used to estimate skeletal muscle volume at enrollment
and at the end of the intervention period. Skeletal muscle areas were calculated on
axial
sections at the level of the third lumbar vertebra (L3) of CT images (Philips 256
iCT),
using IntelliSpace Portal software. The psoas major, erector spinae, quadratus lumborum,
transversus abdominis, extra-abdominal oblique, and intra-abdominal oblique muscles
were
delineated by density thresholds ranging from −29 to 150 Hounsfield units. The muscle
area
(cm2 ) at the L3 level was normalized by the square of height (m2 ) to
obtain SMI at L3 (L3 SMI, cm2 /m2 ). Grip strength was measured at
enrollment and every month during the study period using a KYTO 2324-type grip force
meter.
Two measurements were obtained from each hand and the average of the higher right-
or
left-sided values was recorded as the grip strength value.
Diagnosis of sarcopenia
According to the Chinese criteria [14 ], sarcopenia is defined as the presence of decreased handgrip strength (<25 kg for
men and <18 kg for women) and decreased muscle mass (SMI < 50
cm2 /m2 for men and <39 cm2 /m2 for
women).
Ethical Statement
Written informed consent was obtained from each patient included in the study, and
the
study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki
as
reflected in a priori approval by the Ethics Committee of the
Sixth People’s Hospital of Cheng Du (APPROVAL NUMBER: 2019-S-004, 5 November 2019).
Statistical analysis
All statistical analyses were performed using the SPSSAU data scientific analysis
platform (http://spssau.com/ ). Categorical variables
were described by quantity and percentage and compared by Chi-square test. The normally
distributed continuous variables are described as the means with the standard error
(mean ±
SEM) and compared by one-way analysis of variance (ANOVA) to determine significant
differences within or between the groups. The post hoc
Student–Newman–Keuls analyses were used when significance was found. A p value less
than 0.05 was considered statistically significant.
Results
Patient Characteristics
Conventional treatments such as liver protection, anti-virus drugs, and diuretic therapy
were administrated to patients during the study period. Out of 127 enrolled participants,
124 completed the intervention, and there were 3 dropouts. Two patients were unable
to
tolerate a late evening snack because of the discomfort related to BCAA supplementation
in
the first week, one in group A and another in group C. One patient were excluded because
of
moving to another area in group B. None of the patients decreased food intake during
dinner
because of the late evening snack. There were no adverse events caused by the interventions.
[Table 1 ] presents the baseline characteristics of group A (n = 41), group B (n = 42), and
group C (n = 41). No significant differences were observed between groups.
Table 1 Baseline characteristics of participants.
Group A (n=41)
Group B (n=42)
Group C (n=41)
p Value
Categorical variables are given as numbers. Continuous variables are given as
medians and ranges in parentheses. BMI, body mass index; HBV, hepatitis B virus;
NAFLD, nonalcoholic fatty liver disease; ALT, alanine aminotransferase; AST,
aspartate aminotransferase; ALP, alkaline phosphatase; BCAA, branched-chain amino
acid; SMI, skeletal muscle mass index.
Age (years)
56.29±9.88
57.12±7.76
55.78±9.01
0.788
Gender (male/female)
27/14
31/11
23/18
0.237
Etiology (HBV/alcohol/NAFLD/others)
18/9/12/2
22/10/7/3
28/4/7/2
0.307
Child–Pugh grade (A/B)
22/19
28/14
21/20
0.309
BMI (kg/m2 )
23.09±2.83
22.37±2.83
22.64±3.04
0.525
ALT (U/L)
85.00±61.75
76.57±44.89
71.71±44.78
0.493
AST (U/L)
66.34±43.56
56.05±29.66
58.71±34.72
0.413
ALP (U/L)
117.10±68.73
112.79±79.51
101.05±48.15
0.533
Serum albumin (g/L)
32.07±4.73
33.40±4.73
31.97±4.14
0.282
Total bilirubin (μmol/l)
38.25±14.88
33.92±11.04
37.80±13.58
0.246
Prothrombin time (%)
62.59±10.62
62.55±9.95
62.32±10.79
0.992
BCAA (μmol/l)
454.73±40.48
452.10±42.79
454.37±37.24
0.949
Daily steps
5753.56±907.52
5554.40±746.91
5830.44±839.64
0.300
Grip strength (kg)
25.73±4.95
26.62±6.39
24.08±6.19
0.143
SMI (cm2 /m2 )
50.96±8.44
49.66±9.04
48.21±9.06
0.375
Sarcopenia (yes/no)
11/30
12/30
14/27
0.751
Comparison of Muscle Mass, Muscle Strength, and Blood Indicator Variables Among
Groups
Comparisons of pre- and post-intervention changes among groups in muscle mass, muscle
strength, and blood indicator variables are shown in [Table 2 ]. Serum albumin and daily steps were significantly increased after 3-month
interventions in all groups (p =0.0001). In group A, remarkable
post-intervention increases in BCAA (p =0.001) and grip strength
(p =0.020) were observed. Meanwhile, in group C,
post-intervention elevation of BCAA (p =0.005), grip strength
(p =0.0001), and SMI (p =0.0001) were
seen. Prevalence of sarcopenia was significantly decreased in group C after intervention
(p =0.015). Between-group comparisons showed serum BCAA levels
were significantly higher after nutrition supplementation in group A (group A vs B,
p =0.001) and group C (group C vs B, p =0.012;). Meanwhile, daily average steps in group B (group B vs A, p =0.0001) and group C (group C vs A, p =0.0001), after an additional 2000 steps/day prescribed through WeChat, were more
than those in group A. Post-intervention grip strength (group C vs A, p =0.020; group C vs B, p =0.036) and SMI (group C vs A,
p =0.035; group C vs B, p =0.012) in
group C were significantly greater than in the other two groups. No other significant
differences were observed within and between groups.
Table 2 Comparison of Muscle Mass, Muscle Strength, and Blood Indicator Variables Among
Groups After 3-Month interventions.
Group A (n=41)
Group B (n=42)
Group C (n=41)
p Value
Baseline
Post intervention
Baseline
Post intervention
Baseline
Post intervention
*p < 0.05 vs baseline; a
p < 0.05 vs group A; b
p < 0.05 vs group B; BMI, body mass index; ALT, alanine
aminotransferase; AST, aspartate aminotransferase; ALP, alkaline phosphatase; BCAA,
branched-chain amino acid; SMI, skeletal muscle mass index.
BMI (kg/m2 )
23.09±2.83
23.25±1.99
22.37±2.83
22.51±2.38
22.64±3.04
23.20±2.94
0.533
ALT (U/L)
85.00±61.75
75.34±43.69
76.57±44.89
63.60±34.69
71.71±44.78
62.12±33.30
0.186
AST (U/L)
66.34±43.56
70.29±42.12
56.05±29.66
65.38±33.58
58.71±34.72
72.29±31.84
0.274
ALP (U/L)
117.10±68.73
104.32±50.20
112.79±79.51
112.24±49.56
101.05±48.15
110.22±46.90
0.836
Serum albumin (g/L)
32.07±4.73
35.47±3.26*
33.40±4.73
36.12±3.70*
31.97±4.14
35.37±3.56*
0.0001
Total bilirubin (μmol/l)
38.25±14.88
37.06±11.37
33.92±11.04
36.39±11.68
37.80±13.58
37.98±11.48
0.622
Prothrombin time (%)
62.59±10.62
59.22±9.34
62.55±9.95
60.83±8.39
62.32±10.79
61.95±8.61
0.570
BCAA (μmol/l)
454.73±40.48
482.85±32.81*b
452.10±42.79
456.98±34.02
454.37±37.24
477.37±30.02*b
0.0001
Daily steps
5753.56±907.52
6316.85±1067.32*
5554.40±746.91
7998.38±1072.02*a
5830.44±839.64
8292.10±1042.85*a
0.0001
Grip strength (kg)
25.73±4.95
28.53±4.09*
26.62±6.39
28.81±5.52
24.08±6.19
31.32±4.94*ab
0.0001
SMI (cm2 /m2 )
50.96±8.44
51.49±6.92
49.66±9.04
50.76±7.28
48.21±9.06
55.22±6.74*ab
0.004
Sarcopenia (%)
26.83
24.39
28.57
26.19
34.15
9.76*
---
Time Course of Changes in Plasma BCAA and Daily Steps
The time course of changes in serum BCAA and daily steps are shown in [Fig. 2 ]. The average level of BCAA in the blood was significantly increased in both group
A
and group C after nutrition supplementation (group A, 482.85±32.81 vs 454.73±40.48,
p =0.001; group C, 477.37±30.02 vs 454.37±37.24, p =0.005;). Contrarily, there was no significant change between day 0 and 3 months
in Group B (456.98±34.02 vs 452.10±42.79, p =0.525). Disparity
among groups appeared after the first month. Remarkably, promoted BCAA concentrations
were
observed in group A (group A vs B, 482.85±32.81 vs 456.98±34.02, p =0.001) and group C (group C vs B, 477.37±30.02 vs 456.98±34.02, p =0.012) at the end of 3 months. Significant increases in average
daily steps were observed in each group since the end of month 1. Meanwhile, after
an
additional 2000 steps/day prescribed, the average number of daily steps were more
in group B
(group B vs A, 7998.38±1072.02 vs 6316.85±1067.32, p =0.0001) and
group C (group C vs A, 8292.10±1042.85 vs 6316.85±1067.32, p =0.0001) than in group A. These results preliminarily confirmed the effect of
interventions in each group.
Fig. 2 Time course of changes in plasma BCAA a and daily steps
b . Group A vs B, #p < 0.05; Group B vs C, &p <
0.05; Group A vs C, †p < 0.05; BCAA, branched-chain amino acid.
Time Course of the Change Rates in SMI and Grip Strength
The median change rates of SMI from day 0 were 1.26% at 3 months in group A, 2.33%
in
group B, and 13.00% in group C. A significant difference was observed among groups
at 3
months (p =0.0001), shown in [Fig. 3 ]a. The change rates of grip strength from day 0 were 6.10% at 1 month, 8.18% at 2
months and 10.12% at 3 months in group A. Similarly, change rates of grip strength
from day
0 were 4.53% at 1 month, 5.72% at 2 months, and 7.59% at 3 months in group B. Meanwhile,
in
group C, change rates of grip strength from day 0 were 14.85% at 1 month, 18.69% at
2
months, and 23.53% at 3 months, which were significantly greater than in any other
two
groups (p =0.0001), as shown in [Fig. 3 ]b. These results demonstrated that a combination of unsupervised walking exercise
and
BCAA was more effective in improving skeletal muscle mass and strength than those
administrated alone in patients of cirrhosis.
Fig. 3 Time course of the change rates in SMI a and grip strength
among groups b . Group A vs B, #p < 0.05; Group A vs C, †p
< 0.05; SMI, skeletal muscle mass index.
Prevalence of Sarcopenia in Groups
Sarcopenia were respectively diagnosed in 11 patients in group A (11/41, 26.83%),
in 12
patients in group B (12/42, 28.57%), and in 14 patients in group C (14/41, 34.15%)
at the
beginning of this study. At 3 months, 10 patients in group A and 11 patients in group
B
remained sarcopenic. No significant differences were observed in either group A and
group B
(p =0.500), but in group C, 10 out of 14 patients no longer met
the diagnostic criteria at 3 months. Thus, the prevalence of sarcopenia was significantly
reduced to 9.76% in group C (p =0.007), as detailed in [Fig. 4 ]. These results suggested walking exercise plus BCAA supplementation was more useful
in treating sarcopenia in LC patients with Child–Pugh A/B.
Fig. 4 Prevalence of sarcopenia at day 0 and 3 months in groups.
Discussion
In this study, parameters reflecting skeletal muscle mass and muscle strength were
evaluated after 3 months of interventions in participants of LC. Since it’s hypothesized
that
an earlier intervention at a time when anabolic potential exists may be more effective
than an
intervention at a refractory stage of muscle wasting [15 ], patients with Child–Pugh class A/B were enrolled. As we know, management of CLD
is a
long-term process and hospitalizations were not always essential in this population.
Nowadays,
the vast majority of people own smartphones; smartphone applications may have the
chance to
provide a more continuous and easily expandable method of outpatient disease monitoring.
However, data about the use of these communication tools in cirrhosis with sarcopenia
and
pre-sarcopenia are still insufficient. To the best of our knowledge, we first conducted
this
prospective controlled study to demonstrate that an unsupervised walking exercise
using WeChat
combined with BCAA supplementation benefits muscle conditions and prevents progress
of
sarcopenia in LC adults.
Onset and progression of sarcopenia include malabsorption, dysregulated metabolism,
reduced nutritional intake, hormonal alterations, increased loss of muscle, and hyperammonemia
[16 ]. Cirrhosis is a state of accelerated starvation caused by abnormal liver function.
Within 10 h of fasting in patients with cirrhosis, fatty acid oxidation, muscle, and
hepatic
glycogen reduction are equivalent to what would be observed in healthy subjects after
3 days
of starvation [17 ]. Low glycogen stores increase the need for gluconeogenesis, resulting in impaired
muscle biosynthesis and increased muscle proteolysis. Nevertheless, nutritional and
metabolic
alterations do not explain all of the low muscle mass in cirrhosis. The exact mechanism
contributing to muscle atrophy in cirrhosis has not been clearly identified. Nutritional
therapy, especially BCAA supplementation, has shown significant benefit, while studies
on
exercise have been controversial [18 ]. Applying acute exercise to cirrhosis individuals might be challenging because of
stimulating oxidative stress and proinflammatory cytokines synthesis, which in turn
lead to
liver damage, portal hypertension, and development of complications [19 ]. Meanwhile, infrequent physical activity with low intensity might be more useful
with
no decompensation events associated with exercise [9 ]. As mentioned above, high acceptance but low usage of smartphone applications was
reported for the management of cirrhosis [12 ]. We believe that setting an achievable goal is important, considering the lower
level
of daily activity in cirrhosis individuals than in the general republic. Therefore,
an
additional 2000 steps/day were prescribed through the WeChat application in the form
of
unsupervised walking in the current study. As displayed in [Fig. 2 ], average daily steps began to increase from the end of month 1, until there were
far
more than 2000 steps over the intervention period in patients administered walking
exercise. A
similar trend was observed in patients who received BCAA treatment alone, but a rising
number
of daily steps remains remarkably higher in group B and group C after 3 months. This
could be
attributed to goal setting and maintenance of exercise habits in patients conducting
walking
exercises. Besides, walking activity using WeChat indicates good compliance and safety
through
unsupervised exercise. No participants dropped out owing to adverse events associated
with
exercise, no significant changes in laboratory data were seen except an ascent of
albumin in
research. The advising of unsupervised physical activity of low to medium intensity
through
the smartphone application seems to be workable and helpful in forming an exercise
habit in LC
patients of Child–Pugh A/B. However, no benefits in skeletal muscle mass and prevalence
of
sarcopenia were established in participants undertaking exercise alone, even in grip
strength.
We think this may be due to the low intensity of walking and no resistance training
being
provided [20 ]. Of course, unchanged grip strength could also be explained by the lower limb muscles
being affected during walking but not the wrist muscles. Interestingly, the combination
of
walking exercise and BCAA supplementation results in a different effect. Post-intervention
SMI
and grip strength were significantly improved, as well as when compared between groups
of
these provided alone. The prevalence of sarcopenia also declined in group C. There
is strong
evidence BCAA plays an important role in the formation and maintenance of the skeletal
muscle
[21 ]. BCAAs, particularly leucine, activate the mammalian target of rapamycin (mTOR)
signaling, stimulating the synthesis of glycogen and proteins [22 ]. Moreover, BCAA plays a compensatory role in ammonia detoxification and clearance
in
cirrhosis [23 ]
[24 ]
[25 ]. Accumulation of ammonia in muscle results in mitochondrial dysfunction, which in
turn
causes muscle oxidative damage, further exacerbating sarcopenia [26 ]. It was reported that chronic liver disease has a low serum level of BCAA [27 ]. Concentrations of BCAA were significantly related to muscle mass and muscle strength
in cirrhosis, even in those not receiving BCAA supplementation [1 ]. A recent meta-analysis suggested BCAA improves SMI and mid-arm muscle circumference
in sarcopenia with cirrhosis [4 ]. We similarly noted the efficiency of oral BCAA supplementation. As revealed in
our
study, serum BCAA, albumin, daily steps, grip strength, and SMI were elevated in group
A after
3 months of oral supplementation, though not statistically in SMI. The insignificant
changes
in SMI could be partially explained by the short intervention duration compared with
previous
literature. We also suggested the coordinated action of walking exercise and BCAA
supplementation in ameliorating sarcopenia. Several pre-post-interventional designed
studies
[1 ]
[7 ]
[8 ] have shown the superiority of BCAA combined with exercise. In a randomized trial
[9 ], lower thigh circumference and the 6 min walking test were significantly improved
in
cirrhosis patients (n=8) with combined interventions, compared with patients (n=9)
with no
intervention. In a study of elderly women with sarcopenia [28 ], muscle volume and function showed greater improvements with both BCAA supplementation
and exercise for 3 months than with only BCAA supplementation. In the present study,
we
emphasized a comparison between different interventions and found that exercise plus
BCAA
supplementation might be more superior in improving SMI, grip strength, and sarcopenia
than
those given alone in relatively early cirrhosis, or at least the effect of nutrition
supplementation was moved up according to the time course of the change rates in SMI
and grip
strength ([Fig. 2 ]) in consideration of previous studies [1 ]
[7 ]
[8 ]. Aerobic exercise, such as walking, was found to contribute to the inductions of
mitochondrial biogenesis and dynamics and mitochondrial metabolism restoration, as
well as to
decrease the catabolic genes expression and increases muscle protein synthesis [29 ]. Exercise upregulates insulin-like growth factor 1 (IGF-1), which brings
downregulation of myostatin, resulting in improvement of insulin sensitivity and an
increase
in muscle protein synthesis [30 ]. However, production of ammonia elevates at the same time [31 ]. After exercise, BCAAs help to increase muscle mass and improve insulin resistance
and
glucose uptake in the muscles [32 ]. Meanwhile, BCAAs may work as substrates in ammonia metabolism in skeletal muscles,
as
mentioned above [25 ].
Compared with previous trials, WeChat, a smartphone application, was used to guide
the
urban-life-based exercise of cirrhosis patients in this study. There were several
advantages.
First, WeChat has been widely used in China. The application would remind patients
to exercise
and record steps automatically. WeChat would save the time of patients who no longer
need to
come back to hospital for guided training. In addition, patients and research assistants
could
communicate with each other once needed. It has little impact on patients’ normal
lives and is
relatively safer than patients doing exercise alone. Finally, WeChat is free, and
it is cost
effective for the management of chronic diseases such as liver cirrhosis.
There are some limitations in this study. First, this study was not a randomized control
trial, and no placebo group was set because the ethics committee insisted that all
patients
should have the right to select their disease management mode, and all patients should
be
provided appropriate interventions. Second, the period of the study was short, and
we are
unable to investigate changes of SMI every month, for we used radiological examination
to
calculate SMI. Furthermore, we didn’t include data of blood ammonia and health-related
quality
of life. That will be our next exploration approach. Nevertheless, our findings indicated
the
effectiveness and feasibility of a combination of unsupervised walking using a smartphone
and
BCAA supplementation for ameliorating skeletal muscle mass and strength in Child–Pugh
class
A/B cirrhosis patients.
Conclusion
In conclusion, the present study suggests that the combination of unsupervised walking
exercise using smartphone applications and BCAA supplementation might be an effective
and safe
treatment option for cirrhosis patients with Child–Pugh class A/B to improve skeletal
muscle
mass and strength or prevent progress of sarcopenia.
Data availability statement
Data availability statement
Supplementary material associated with this article can be found, in the online version,
at http://www.chictr.org.cn/showproj.aspx?proj=55293 .
Clinical trial results
Trial registration: 06–27–2020; registration number: ChiCTR2000034175. Posting in
registry
of results of the same or closely related work: none.
