Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : OC44 - OC48 Full Version

Current Practice of Branched Chain Amino Acids Administration in Patients with Liver Cirrhosis: A Physician Survey


Published: August 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/48605.15241
Vaishali Bhargava, Kushal Sarda, Srirupa Das

1. Medical Advisor, Established Pharmaceuticals Divsion, Abbott India Limited, Mumbai, Maharashtra, India. 2. Senior Medical Affairs Manager, Established Pharmaceuticals Divsion, Abbott India Limited, Mumbai, Maharashtra, India. 3. Director, Medical Affairs, Established Pharmaceuticals Divsion, Abbott India Limited, Mumbai, Maharashtra, India.

Correspondence Address :
Dr. Vaishali Bhargava,
Medical Advisor, Established Pharmaceuticals Divsion, Abbott India Limited,
Mumbai, Maharashtra, India.
E-mail: vaishali.b@abbott.com

Abstract

Introduction: Protein Energy Malnutrition (PEM) is prevalent in about 65-90% of patients with liver disorders. PEM is usually associated with poor quality of life, high risk of complications, morbidity and mortality, and longer duration of hospital stays. PEM is also associated with decreased skeletal muscle mass and reduced levels of serum albumin and Branched Chain Amino Acids (BCAAs). Therefore, BCAAs are recommended as nutritional therapy in various liver disorders.

Aim: To understand the current practice of BCAA use in patients with liver cirrhosis in India.

Materials and Methods: A cross-sectional, questionnaire-based survey was conducted pan India involving 100 gastroenterologists over a period of four months from September 2019 to December 2019. Each physician participated in the survey after verbal consent. Ample time was given for completion of the questionnaires.

Results: Out of 83 participating physicians, nearly 3/4th considered liver cirrhosis as the most common Gastrointestinal (GI) disorder where nutrition is important in patient management. Malnutrition was commonly observed in patients with cirrhosis by nearly over 80% physicians and was most common in patients with decompensated cirrhosis. Weight loss and loss of appetite can be early signs of sarcopenia as these were common profiles observed in patients with malnutrition. Total 51.8% physicians considered BCAA administration in all Child-Pugh class patients. The practice of BCAA treatment with regards to its dose and duration highly varied for patients with cirrhosis, Hepatic Encephalopathy (HE), and Liver Transplantation (LT). Proteins from vegetarian source (50.6%) and BCAA supplementation (96.4%) were considered as major treatments for HE patients. Majority of the physicians reported that BCAA administration improved quality of life (52.4%), reduced HE episodes (49.4%), improved muscle mass (50%), and reduced hospitalisation rates (49.4%) in 20-40% of their patients. In all, 92.8% of physicians suggested that early administration of oral BCAA can prolong the waiting period for LT.

Conclusion: Branched Chain Amino Acids (BCAA) is an integral part of nutritional management in patients with liver cirrhosis in India. Further studies are required to guide the decision on dose and duration of BCAA treatment in the management of cirrhosis.

Keywords

Amino acid supplementation, Hepatic encephalopathy, Liver transplantation, Management

Nutrition is an integral part of human health. It also plays an important role in various clinical disorders. In particular, nutrition is critical to the management of various GI disorders (1). Considering the importance of nutrition in liver disorders, European Association for the Study of the Liver (EASL) guidelines were released in 2019, which provided insights on screening, assessment and principles of nutritional management. These guidelines provide recommendations for nutritional management in specific populations such as patients with HE or those undergoing LT (2). It is emphasised that malnutrition in the form of sarcopenia is observed in nearly 20-50% of patients with compensated and decompensated liver cirrhosis, respectively (3).

Malnutrition also affects the Quality of Life (QoL) in these patients (4). Thus, managing adequate nutritional requirements in liver cirrhosis is crucial. The EASL guidelines recommended use of BCAA and leucine-rich amino acids supplementation in patients with decompensated cirrhosis whose nitrogen intake is not adequately achieved with oral diet. Further, BCAA supplementation is recommended especially for patients with HE to improve neuropsychiatric performance (2). Additionally, sarcopenia is identified as a predictor of mortality in liver cirrhosis, and supplementation with BCAA improved the survival in sarcopenic cirrhotic patients (5). Evidence also indicates sarcopenia being a predictor of mortality in patients undergoing living donor LT (6). These data indicate the importance of nutritional management in patients with liver cirrhosis.

Very few clinical studies have evaluated the role of nutritional therapy in patients with liver cirrhosis from India. A study by Maharshi S et al., observed improvement in QoL after nutritional therapy (30-35 kcal/kg/d, 1.0-1.5 g vegetable protein/kg/d) in cirrhotic patients with minimal HE (7). However, published evidence pertaining to the role of BCAA in nutrition of cirrhotic patients is lacking. Additionally, there are no guidelines in India concerning the use of BCAA for liver cirrhosis. Thus, to understand the current practice of BCAA supplementation in patients with liver cirrhosis in the Indian setting, the present cross-sectional survey of physicians involved in the management of liver cirrhosis and LT was conducted.

Material and Methods

This cross-sectional questionnaire-based survey was conducted from September 2019 to December 2019 across India. The participating physicians were gastroenterologists who had immense experience in the management of liver cirrhosis. The study setting included hospitals and/or clinics of practicing gastroenterologists. Written informed consent was obtained from all survey participants, and physician confidentiality and anonymity were maintained throughout the study conduct. In accordance with local legislation and national guidelines, as this survey did not involve any intervention or direct participation of a patient, ethical approval by an independent ethics review board was not required.

Survey instrument: The survey instrument was a questionnaire designed to assess the current practice of BCAA use in management of liver cirrhosis. It consisted of 15 open and closed ended questions pertaining to various aspects of physician practice with respect to BCAA use. The validated questionnaire (approval no. INDUSG193920) is shown in (Table/Fig 1). Questions were pertinent to initiation of BCAA, dose, duration in different indications, and possible observed outcomes with BCAA use. All physicians who verbally consented for participation in the survey were given adequate time to respond to the questionnaire. Duly filled questionnaires were collected from the physicians.

Statistical Analysis

Data from the questionnaire were entered and analysed using Microsoft Excel. Proportion of physicians responding to each question were determined. Data were presented as frequency and percentages for each question.

Results

Across India, 100 gastroenterologists were approached, out of which 83 provided informed consent and provided responses to all the survey questions. Liver cirrhosis was considered to be the most common GI disorder where nutrition was observed to play an important role. It was the first choice of 3/4th of the participants across various disorders. Following liver cirrhosis, chronic pancreatitis, inflammatory bowel disease, and non alcoholic fatty liver disease, in that order, were considered to be conditions where nutrition played an important role in disease management (Table/Fig 2).

Total, 63 (75.9%) and 61 (73.5%) physicians responded for the question of number of patients sufferring from malnutrition and sarcopenia in decompensated and compensated cirrhosis respectively. Over 50% of physicians reported that >60% of the patients with decompensated cirrhosis suffer from malnutrition, whereas n=61 physicians reported that <40% of patients with compensated cirrhosis have malnutrition in routine practice (Table/Fig 3).

Among patients presenting with sarcopenia/malnutrition, unintentional weight loss of >6 kg in the last 6 months and decreased appetite over the last month were observed as common presentations by 55.4% and 42.2% physicians, respectively. Moreover, 27.7% physicians reported unintentional weight loss of >3 kg in the last month as one of the presentations (Table/Fig 4).

When considering BCAA administration per Child-Pugh grading, 51.8% physicians considered all grades (A, B, and C) for BCAA use in patients with cirrhosis, whereas 44.6% considered BCAA use only in patients with grades B and C (Table/Fig 5).

Majority of physicians (71.1%) considered serum albumin ≤3.5 gm/?dL as common indication for BCAA initiation in decompensated cirrhosis. This was followed by BCAA to tyrosine ratio (BTR) ≤3.5, which was considered by 37.3% physicians. Other indications included prothrombin activity ≤60% and platelet count of ≤100 000/?mm3 by nearly equal number of participants (Table/Fig 6).

Dose and duration of BCAA treatment for patients with cirrhosis, HE and patients listed or undergoing LT are shown in (Table/Fig 7). With regards to the dose and duration of BCCA treatment in different liver conditions, we received 69 (83.1%) and 64 (77.1%) physicians responses, respectively. For patients with cirrhosis, dose varied among the physicians, with 21.7% recommended doses ≤10 gm/day and 23.2% recommended doses >10 gm/day. Frequency was predominantly twice a day as stated by 55.1% of physicians. The duration was considered to be ≤3 months by 43.6% of physicians, whereas 29.7% considered duration to be ≥6 months. Some suggested continuation over long-term or until transplantation.

For patients with HE, doses of ≤10 gm/day and >10 gm/day were stated by 21.4% and 15.7% of the physicians, respectively. Frequency was predominantly twice a day as stated by 48.6% of physicians. Majority (61.5%) recommended treatment duration of ≤3 months, whereas 18.5% recommended duration of >6 months. In all, 6.2% of physicians were of the opinion that BCAA should be continued until transplantation.

For patients on the waiting list or those undergoing LT, lower number physicians (n=41) commented on dose and duration of BCAA treatment. The number of physicians choosing doses of ≤10 gm/day or >10 gm/day was similar. In total, 39% and 22% of physicians recommended twice a day or thrice a day dosing, and a few suggested BCAA use four times a day. Nearly one third (31.7%) physicians considered duration of therapy to be >6 months or until transplantation.

For management of HE, 94% of physicians considered Fischer ratio imbalance to be a critical factor. As high as 96.4% considered BCAA administration as a treatment option, whereas 50.6% physicians considered dietary vegetarian protein source as essential. The combination of vegetarian source of dietary protein and BCAA together was most preferred combination (48.2%) as shown in (Table/Fig 8).

Improving muscle mass, reducing HE episodes and improving QoL were considered to be the indicators for assessing BCAA efficacy in patients with cirrhosis or HE or those undergoing LT. In routine practice, nearly half of the participating physicians observed that 20%-40% of their patients showed improvement in QoL (52.4%), reduction in HE episodes (49.4%), increase in muscle mass and reduction in hospitalisation rates (49.4%). Furthermore, nearly one third observed improved QoL, reduced HE episodes and increased muscle mass in 40%-60% of their patients, whereas nearly one-fourth of physicians observed reduction in hospitalisation rates in 40%-60% of patients.

As high as 92.8% physicians considered that early administration of oral BCAA can prolong the waiting period for LT.

Discussion

Nutrition is one of the important management aspects for patients with liver cirrhosis. EASL guidelines have specified nutrition recommendation for these patients (2). BCAA is an important nutrition therapy for management of liver cirrhosis. In liver disorders, BCAA acts via multiple mechanisms. It has shown to induce mitochondrial biogenesis, inhibit reactive oxygen species production, stimulate albumin and glycogen synthesis, inhibit hepatocyte apoptosis and promote hepatocyte regeneration, stimulate hepatocyte growth factors, improve insulin resistance, as well as induce dendritic cell maturation (8). As malnutrition is more common in decompensated cirrhosis as observed from this survey and from previous reports, it needs attention (3). Though quantitative methods such as computed tomography-based assessment of muscle mass are best for screening and detecting sarcopenia, these may not be feasible in all patients in routine clinical practice (2).

Alternatively, body mass assessment using anthropometric measures can be used to determine sarcopenia (2). In clinical practice, physicians considered that unintentional weight loss of >6 kg in the last 6 months can be one of the indicators of sarcopenia. Also, changes in diet as assessed from dietary interviews can be another indicator. Authors have observed that atleast 42.2% of physicians considered weight loss or decreased appetite over the last month as one of the presentations in patients with sarcopenia. EASL guidelines recommend assessment of dietary intake by trained personnel in terms of quality and quantity of food and supplements, fluids, sodium in diet, number and timing of meals during the day and barriers to eating in sarcopenia (2).

Severity of liver cirrhosis is graded by using Child-Pugh criteria. A total of 51.8% physicians suggested use of BCAA despite severity of disease whereas 44.6% considered its use in grades B and C only. A study by Habu D et al., observed that BCAA administration was able to maintain serum albumin for two years in both compensated as well as decompensated cirrhosis (9). Another study by Nishiguchi S and Habu D identified that early administration of BCAA in cirrhosis with Child-Pugh classes A and B can help achieve better prognosis and maintain QoL (10). Evidence also indicates that BCAA administration in early disease is associated with increasing total hepatic parenchymal cell mass (8). These data indicate that BCAA supplementation should be done irrespective of the severity of cirrhosis. This was practiced by nearly half of all the physicians in the survey. Majority of the physicians considered hypoalbuminemia followed by BTR as indicators to initiate BCAA in decompensated cirrhosis. However, it should be noted that in patients with malnutrition, BTR declines before the reduction in serum albumin is evident, thereby indicating that BTR is a useful tool to decide appropriate time for the use of BCAA (11).

The duration and dose of BCAA for cirrhosis and its complications may vary in different parts of the world. In present survey it was found that there are varying doses and duration of treatment with BCAA in patients with liver cirrhosis, HE as well as in patients with LT. EASL guidelines identify that long-term supplementation of oral BCAA may be of better nutritional value (2). In a study by Park JG et al., BCAA (12.45 g) administration daily for atleast six months was associated with significant improvement in model for end-stage liver disease score in patients with advanced cirrhosis (12). Another study in patients with decompensated cirrhosis, orally administered BCAA at 12 gm/day for two years resulted in improved event-free survival, serum albumin concentration, and QoL (13). An Italian study in patients with liver cirrhosis reported improvement in both the serum bilirubin levels and Child-Pugh scores with long-term (one year) BCAA supplementation (14). In patients with decompensated cirrhosis, oral BCAA at 12 gm/day for two years resulted in reduction in the risk of HE (15). These evidences indicate that BCAA should be administered for atleast six months or more to attain beneficial effects in patients with cirrhosis.

During the treatment with BCAA, Fischer ratio is critical to the management of HE as was agreed by 94% of physicians. Amino acid imbalance becomes more marked with increasing severity of liver disease. A lower Fischer ratio is associated with HE (8). In managing HE, oral dietary protein intake is preferred as indicated in the EASL guidelines. BCAA supplementation is necessary in all HE patients to improve neuropsychiatric performance and to reach the recommended nitrogen intake (2). This was evident in the survey where dietary protein intake and BCAA both were preferred by majority of the physicians. Preference was given to proteins from vegetarian sources because it has shown to be associated with significantly better nitrogen balance in patients with HE (16).

In assessing the efficacy of BCAA, QoL, frequency of HE episodes, and increase in muscle mass were major indicators. Also, majority of the physicians suggested that 20% to 60% of patients with cirrhosis demonstrate positive impact on these outcomes, including reduced rates of hospitalisation. Evidence from clinical studies indicate that BCAA supplementation is associated with improved QoL (17), reduced hospitalisation rates (14), and improvement in minimal HE and muscle mass (18).

Studies also indicate that BCAA supplementation significantly lowers the composite outcome of all cause mortality, development of liver cancer, rupture of oesophageal varices, or progress of hepatic failure and therefore prolongs event-free survival (13). In addition, majority of physicians suggested that BCAA administration prolonged the LT waiting period. A study by Kawamura E et al., reported that early interventional oral BCAAs might prolong the LT waiting period because of preservation of hepatic reserve in patients with cirrhosis (19). However, further research is needed to substantially establish the role of BCAA in patients undergoing LT.

Limitations(s)

Although attempts were made to enrol participating gastroenterologists across India to reflect clinical practice pan India, the relatively low sample size and chances of recall bias among the physicians limit the generalisability of the survey findings. Future prospective studies with larger sample sizes and robust design are therefore warranted.

Conclusion

In this first of its kind survey among physicians in India, which assessed the practice of oral BCAA supplementation in patients with liver cirrhosis, majority of the physicians considered nutrition as a critical part of patient management and recommended BCAA use irrespective of disease severity. Though dose and duration of BCAA varied among the participating physicians, they emphasised the need for long-term administration for atleast six months or beyond to achieve better clinical outcomes. Dietary vegetarian proteins along with BCAA supplementation were considered advisable in patients with HE. BCAA administration can improve the quality of life and muscle mass, reduced hospitalisation rates in cirrhotic patients, and could prolong the waiting time for LT.

Acknowledgement

The authors would like to thanks Dr. Vijay M Katekhaye (HP Creation) for assisting in the development of this manuscript.

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DOI and Others

10.7860/JCDR/2021/48605.15241

Date of Submission: Feb 04, 2021
Date of Peer Review: May 17, 2021
Date of Acceptance: Jul 14, 2021
Date of Publishing: Aug 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: Funded by Abbott India Limited, Mumbai, Maharashtra, India
• Was Ethics Committee Approval obtained for this study? NA
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 05, 2021
• Manual Googling: Jun 06, 2021
• iThenticate Software: Jul 31, 2021 (8%)

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