The evaluation of gastrointestinal involvement and nutritional status in systemic sclerosis: identifying risk factors for malnutrition in a cross-sectional study

Abstract

Aims: Gastrointestinal (GI) involvement is frequently observed in Systemic sclerosis (SSc). Considering the effect of GI involvement on SSc patients, the risk of malnutrition might be increased. The study aimed to evaluate GI involvement and the risk for malnutrition and to demonstrate the relationship between disease-related features and risk factors for malnutrition in SSc patients. Methods: SSc-related clinical features and disease severity evaluated with Physician Global Assessment (PGA) were recorded. Detailed GI symptoms and the impact of GI involvement on patients were assessed with the UCLA SCTC GIT 2.0 questionnaire. Nutritional status was evaluated with Body Mass Index (BMI) and the Malnutritional Universal Screening Tool (MUST). Results: 104 SSc patients were involved in the study. Mean age of patients with SSc was 52.24±12.82 years. GI involvement was found in 85.7% of patients. 76% of patients had GI symptoms. The median BMI of patients was 25.3 (9) kg/m² with 4.8% of patients categorized as underweight. The assessment of risk for malnutrition using MUST showed 74% of patients at low risk, 16% at moderate risk, and 9.6% at high risk. No important association was detected between risk groups for malnutrition and UCLA GIT 2.0 score. A significant association was found between moderate to high risk for malnutrition and dcSSc (OR 3.12, %95 CI:1.26-7.73; P=0.01), the presence of GI symptoms (OR 5.32, %95 CI:1.16-24.36; P=0.03), the decrease in oral aperture (OR 0.35, %95 CI:0.15-0.79; p:0.02), and severity of the disease investigated by PGA score (OR 1.52, %95 CI:1.09-2.13; p=0.01). Conclusion: GI involvement is a common manifestation in SSc patients. Approximately 26% of patients were at moderate to high risk for malnutrition. Several SSc-specific clinical features, including disease severity, the presence of GI symptoms, dcSSc, and a decrease in oral aperture were related to a higher risk for malnutrition.

Keywords

• Gastrointestinal involvement
• malnutrition
• MUST score
• risk factors
• systemic sclerosis

References

1. Stern EP, Denton CP. The pathogenesis of systemic sclerosis. Rheum Dis Clin. 2015;41(3):367-382. doi: 10.1016/j.rdc.2015.04.002
2. Pagkopoulou E, Arvanitaki A, Daoussis D, Garyfallos A, Kitas G, Dimitroulas T. Comorbidity burden in systemic sclerosis: beyond disease-specific complications. Rheumatol Int. 2019;39(9):1507-1517. doi: 10.1007/s00296-019-04371-z
3. Elhai M, Meune C, Avouac J, Kahan A, Allanore Y. Trends in mortality in patients with systemic sclerosis over 40 years: a systematic review and meta-analysis of cohort studies. Rheumatol. 2011;51:1017-1026. doi: 10.1093/rheumatology/ker269
4. Domsic R, Fasanella K, Bielefeldt K. Gastrointestinal manifestations of systemic sclerosis. Dig Dis Sci. 2008;53(5):1163-1174. doi: 10.1007/s10620-007-0018-8
5. Thoua NM, Bunce C, Brough G, Forbes A, Emmanuel AV, Denton CP. Assessment of gastrointestinal symptoms in patients with systemic sclerosis in a UK tertiary referral centre. Rheumatol. 2010;49(9):1770-1775. doi: 10.1093/rheumatology/keq147
6. Tyndall AJ, Bannert B, Vonk M, et al. Causes and risk factors for death in systemic sclerosis: a study from the EULAR Scleroderma Trials and Research (EUSTAR) database. Ann Rheum Dis. 2010;69(10):1809-1815. doi: 10.1136/ard.2009.114264
7. Frantz C, Avouac J, Distler O, et al. Impaired quality of life in systemic sclerosis and patient perception of the disease: a large international survey. Semin Arthritis Rheum. 2016;46(1):115-123. doi: 10.1016/j.semarthrit.2016.02.005
8. Steen VD, Medsger Jr TA. Severe organ involvement in systemic sclerosis with diffuse scleroderma. Arthritis Rheum. 2000;43(11):2437-2444. doi: 10.1002/1529-0131(200011)43: 11<2437::Aid-anr10>3.0.Co;2-u

9. Richard N, Hudson M, Wang M, et al. Severe gastrointestinal disease in very early systemic sclerosis is associated with early mortality. Rheumatol. 2019;58(4):636-644. doi: 10.1093/rheumatology/key350
10. Baron M, Bernier P, Côté LF, et al. Screening and therapy for malnutrition and related gastro-intestinal disorders in systemic sclerosis: recommendations of a North American expert panel. Clin Exp Rheumatol. 2010;28(Suppl 58):S42-S46.
11. van den Hoogen F, Khanna D, Fransen J, et al. 2013 classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative. Ann Rheum Dis. 2013;72(11):1747-1755. doi: 10.1136/annrheumdis-2013-204424
12. Walker UA, Tyndall A, Czirják L, et al. Clinical risk assessment of organ manifestations in systemic sclerosis: a report from the EULAR Scleroderma Trials And Research group database. Ann Rheum Dis. 2007;66(6):754-763. doi: 10.1136/ard.2006.062901
13. Smirani R, Poursac N, Naveau A, Schaeverbeke T, Devillard R, Truchetet ME. Orofacial consequences of systemic sclerosis: a systematic review. J Scleroderma Relat Disord. 2018;3(1):81-90. doi: 10.1177/2397198317746966
14. Khanna D, Hays RD, Maranian P, et al. Reliability and validity of the University of California, Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Instrument. Arthritis Care Res. 2009;61(9):1257-1263. doi: 10.1002/art.24730
15. Taş YM, Derviş Hakim G, Keskinoğlu P, et al. The validity and reliability study of the University of California, Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract (UCLA SCTC GIT) 2.0 questionnaire for the Turkish society. Turk J Gastroenterol. 2019;30(3):234-241. doi: 10.5152/tjg.2018.17856
16. Pope J. (2011) Measures of systemic sclerosis (scleroderma): Health Assessment Questionnaire (HAQ) and Scleroderma HAQ (SHAQ), physician- and patient-rated global assessments, Symptom Burden Index (SBI), University of California, Los Angeles, Scleroderma Clinical Trials Consortium Gastrointestinal Scale (UCLA SCTC GIT) 2.0, Baseline Dyspnea Index (BDI) and Transition Dyspnea Index (TDI) (Mahler’s Index), Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR), and Raynaud’s Condition Score (RCS). Arthritis Care Res. 2011;63(Suppl 11):S98-S111. doi: 10.1002/acr.20598
17. Elia M. Screening for malnutrition: a multidisciplinary responsibility. Development and use of the Malnutrition Universal Screening Tool (‘MUST’) for adults. Redditch: BAPEN. 2003.
18. Shreiner AB, Murray C, Denton C, Khanna D. Gastrointestinal manifestations of systemic sclerosis. J Scleroderma Relat Disord. 2016;1(3):247-256. doi: 10.5301/jsrd.5000214
19. Sakkas LI, Simopoulou T, Daoussis D, Liossis SN, Potamianos S. Intestinal involvement in systemic sclerosis: a clinical review. Digest Dis Sci. 2018;63(4):834-844.
20. Meier FM, Frommer KW, Dinser R, et al. Update on the profile of the EUSTAR cohort: an analysis of the EULAR Scleroderma Trials and Research group database. Ann Rheum Dis. 2012;71(8):1355-1360. doi: 10.1136/annrheumdis-2011-200742
21. Nassar M, Ghernautan V, Nso N, et al. Gastrointestinal involvement in systemic sclerosis: an updated review. Medicine. 2022;101(45):e31780. doi: 10.1097/md.0000000000031780
22. Baron M, Hudson M, Steele R. Malnutrition is common in systemic sclerosis: results from the Canadian scleroderma research group database. J Rheumatol. 2009;36(12):2737-2743. doi: 10.3899/jrheum.090694
23. Murtaugh MA, Frech TM. Nutritional status and gastrointestinal symptoms in systemic sclerosis patients. Clin Nutr. 2013;32(1):130-135. doi: 10.1016/j.clnu.2012.06.005
24. Caimmi C, Caramaschi P, Venturini A, et al. Malnutrition and sarcopenia in a large cohort of patients with systemic sclerosis. Clin Rheumatol. 2018;37(4):987-997. doi: 10.1007/s10067-017-3932-y
25. Türk İ, Cüzdan N, Çiftçi V, Arslan D, Doğan MC, Unal İ. Malnutrition, associated clinical factors, and depression in systemic sclerosis: a cross-sectional study. Clin Rheumatol. 2020;39(1):57-67. doi: 10.1007/s10067-019-04598-y
26. Caporali R, Caccialanza R, Bonino C, et al. Disease-related malnutrition in outpatients with systemic sclerosis. Clin Nutr. 2012;31(5):666-671. doi: 10.1016/j.clnu.2012.02.010
27. Krause L, Becker MO, Brueckner CS, et al. Nutritional status as marker for disease activity and severity predicting mortality in patients with systemic sclerosis. Ann Rheum Dis. 2010;69(11):1951-1957. doi: 10.1136/ard.2009.123273