The association between hemoglobin level and sarcopenia in patients with Crohn's disease

doi:10.21203/rs.3.rs-3085225/v1

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The association between hemoglobin level and sarcopenia in patients with Crohn's disease

https://doi.org/10.21203/rs.3.rs-3085225/v1

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Sarcopenia and anemia are common complication in patients with Crohn's Disease (CD). However, few studies have showed the association between sarcopenia and hemoglobin level in patients with CD. This study aimed to explore such association in a Chinese population with CD. Two hundreds and twelve adult CD inpatients who underwent computed tomography (CT) or magnetic resonance imaging (MRI) examinations from July 2019 to December 2021 were included. Sarcopenia was defined according to the cutoff value of skeletal muscle index of lumbar spine 3 (SMI-L3) (< 44.77cm²/m² for male and < 32.5cm²/m² for female). The inpatients with CD were divided into two groups based on the presence or absence of sarcopenia. The clinical data, hemoglobin levels and other laboratory data were retrospectively collected. The association between hemoglobin levels and sarcopenia were identified through univariate and multivariate logistic regression analysis. Sarcopenia occurred in 114 CD patients (53.8%). Compared to patients without sarcopenia, patients with sarcopenia had significantly lower proportion of L1 (30.7% vs 45.8%, p = 0.032) and B1 classification (58.8% vs 72.4%, P = 0.037). Patients with sarcopenia had significant lower level of hemoglobin (Hb) (116.5 ± 22.8 vs 128.1 ± 21.0, p < 0.001). The prevalence of sarcopenia increased with the decrease of hemoglobin level (p for trend < 0.05). Linear regression analysis showed that hemoglobin levels were associated to SMI-L3 (β = 0.091, p = 0.001). Multivariate logistic regression analysis found that higher Hb (OR:0.98; 95% CI: 0.96,0.99; p = 0.034) were independent associated factors for sarcopenia. Lower Hb levels are independent associated factors of sarcopenia in adult inpatients with CD.

Crohn's disease

Montreal classification

sarcopenia

hemoglobin

albumin

fibrinogen

Primary sarcopenia is an age-related muscle failure that is characterized by loss of muscle mass and strength, and/or low physical function [1]. Although sarcopenia is commonly associated with aging, it can also occur in patients with chronic wasting diseases, such as inflammatory bowel disease, malignancy, chronic obstructive pulmonary disease, chronic liver and kidney disease, congestive heart failure, and patients who are chronically bedridden or on steroid therapy [2]. Mechanistically the reduced muscle synthesis may be related to decreased IGF-1, elevated pro-inflammatory cytokines and increased oxidative stress leading to diminished AKT signaling [3, 4]. However, the exact mechanism of sarcopenia remains unknown.

Crohn's disease (CD) is a type of inflammatory bowel disease. Over the last decade, studies found that body composition, including changes in fat, bone loss, osteoporosis, and sarcopenia could occurred in patients with CD [5]. Patients with CD are at risk of malnutrition due to an imbalance between nutritional requirements and caloric loss caused by the catabolic state, especially in patients with an active inflammatory state. Combined with various factors such as a persistent inflammatory state, the incidence of sarcopenia is high [6, 7]. At present, there are few studies showed the associated factors with the development of sarcopenia in patients with CD. In addition, the available findings are somewhat controversial. A few studies suggested that the occurrence of sarcopenia may be related to gender, and Lee et al. [8] reported a higher incidence of sarcopenia in male CD patients, while Galata et al. [9] found the opposite results. Some studies concluded that there were no significant differences in gender, age, Montreal location, behavioral typing, disease activity index and inflammatory marker between patients with and without combined sarcopenia [10]. However, other studies have suggested that C-reactive protein (CRP) is positively associated with the development of sarcopenia and that L2 type is an independent risk factor for sarcopenia [11, 12].

Anemia or low hemoglobin level is common in patients with CD. Moreover, few recent studies showed that anemia was associated with sarcopenia [13, 14]. However, to our knowledge, no study has reported such association in patients with CD. Therefore, we investigated the association between hemoglobin level and sarcopenia in a Chinese population with CD.

2.1. Study Participants

This study retrospectively collected 284 CD inpatients that were hospitalized with small bowel CT enterography (CTE) or small bowel magnetic resonance enterography (MRE) at Jiangsu Province Hospital of Traditional Chinese Medicine between July 2019 and December 2021. The clinical and imaging characteristics of Crohn's patients were recorded. Finally, 212 adult CD patients with complete height information, including 153 males and 59 females, were included. The study was approved by the ethics committee of Affiliated Hospital of Nanjing University of Chinese Medicine (2021-NL02).

The inclusion criteria was as follows: 1) meeting the diagnostic criteria of Crohn's disease; 2) underwent abdominal CT/MR or CTE/MRE examinations and the image was clear to meet the measurement requirements; 3) imaging examinations within 1 month of performing laboratory tests such as routine blood, biochemistry, blood sedimentation, CRP or fecal calprotectin, coagulation function and endoscopy. Exclusion criteria: 1) aged < 18 years; 2) unclear CT or MR images or lack of original DICOM images; 3) pregnant or breastfeeding; 4) incomplete information on laboratory tests such as routine blood, biochemistry, sedimentation, CRP or fecal calcium guard protein; 5) chronic kidney disease, chronic obstructive pulmonary disease, malignancy, congestive heart failure, chronic obstructive pulmonary, neuromuscular disease, activity limitation or prolonged braking; 6) there were no height information.

2.2. Data collection of Crohn's disease patients

The following data were retrospectively collected to determine factors associated with the development of sarcopenia in patients with CD: 1) General information, including sex, age (age at diagnosis and age at the time of imaging), height, time from first symptom presentation to diagnosis, marital history, smoking, alcohol consumption, biologic use, endoscopic granuloma detection, hospital days and hospital costs. 2) laboratory tests: including red blood cell count, Mean red blood cell volume, white blood cell count, platelet count, lymphocyte count, neutrophils, lymphocytes, monocytes, eosinophils, basophils, hemoglobin, hematocrit, CRP, and fecal calprotectinn, serum total protein, serum albumin (Alb), globulin, albumin to globulin ratio, prealbumin, glucose, aspartate aminotransferase, alanine aminotransferase, prothrombin time (PT), activated partial thromboplastin time (APTT), activated partial thromboplastin ratio, fibrinogen (FIB), prothrombin time (PT), D-dimer (D-D) and fibrin (pro) degradation product (FDP) and stool occult blood.

2.3. CTE or MRE imaging

Intestinal wall thickness of the most severe bowel segment, lesion location (L1 type), disease behavior (B1 type), presence of perianal lesions (P), subcutaneous fat thickness around the navel (SFT). Abdominal circumference (AC), skeletal muscle area at the lumbar 3 vertebral level (CSA-L3) were performed using ImageJ, an image analysis software developed by the National Institutes of Health (NIH). When using this software, the identification criteria for CT images of skeletal muscle were − 29 to + 150 HU). For MRI images, muscle area was measure in T1-weighted imaging and identified by difference in tissue signal. The illustration of muscle area measurement on CT and MR images is shown in Fig. 1. CTE/MRE evaluation: images were evaluated and measured by 2 senior physicians who independently observed the images on PACS without knowledge of the patient's colonoscopy, tests, and clinically relevant information.

2.4. Definition of sarcopenia in Crohn's patients

The muscles at the lumbar 3 vertebral level were measured, including the psoas major, erector spinae, multifidus, lumbar square, transverse abdominis, internal oblique, external oblique, and rectus abdominis. The CSA-L3 was the sum of the areas of these muscles. The skeletal muscle index at the lumbar 3 vertebral level (SMI-L3) is calculated from the ratio of CSA-L3 to height squared. Sarcopenia in Crohn's patients was defined by SMI-L3 < 44.77cm /m²² in men and SMI-L3 < 32.5cm² /m² in women [15].

2.5. Statistical analysis

CD patients were divided into two groups according to the sex-specific SMI-L3 cut-off values: sarcopenia group and non-sarcopenia group. Continuous variables conforming to normal or approximately normal distribution were reported as mean ± standard deviation and data were compared between groups using t-test; continuous variables with severe skewed distribution were reported as median (interquartile spacing) and data were compared between groups using wilcoxon rank sum test. The Shapiro-wilk (SW) test was used to test the normality of continuous data. Categorical data were reported as frequencies (percentages) and comparisons between groups were made using the chi-square test or Fisher's exact probability method. Pearson/Spearman rank correlation coefficients were used to assess the correlation between SMI-L3 and vertebral CT values, adiposity parameters, and laboratory examination indices. One-way logistic regression was used to analyze the relationship between sarcopenia and gender, age, Crohn's disease Montreal typing, granuloma detection, and laboratory examination indexes. Variables with p < 0.05 were subjected to mutivariable logistic regression analysis to identify independent associated factors of sarcopenia. Hemoglobin levels were transformed into categorical variables according to quartiles or medians, and linear trend tests were performed by Linear-by-Linear Association (LLA). All statistical tests were two-tailed, and p < 0.05 was considered statistically significant. IBM SPSS statistical software was used for statistical analysis.

3.1.General information

One hundred and fourteen patients were combined with sarcopenia and 98 had no sarcopenia. The differences in the general data of CD patients with and without sarcopenia are shown in Table 1. The occurrence of simple ileal type (L1 type) in patients with sarcopenia which was significantly lower than patients without sarcopenia (30.7% vs 45.8%, p = 0.032). A similar result was observed in non-stenotic non-penetrating type (B1 type) (58.8% vs 72.4%, p = 0.037). There were no statistically significant differences between the two groups in terms of sex, age at diagnosis, time from diagnosis of symptoms, marital history, history of smoking and drinking, fecal occult blood, biologic use, or perianal lesions.

Table 1

Clinical data in CD patients with and without sarcopenia
Variables	Sarcopenia (n = 114)	Non-sarcopenia (n = 98)	P-value
Sex
Male, n (%)	81 (71.1%)	72 (73.5%)	0.295
Age of diagnosis	27 (21,34.5)	29 (21.75,34.5)	0.311
Symptom-to-diagnosis time	12 (3,36)	12 (6,24)	0.482
Marital history (unmarried)	57 (50.9%)	38 (38.8%)	0.078
Smoking (yes)	7 (6.2%)	4 (4.1%)	0.491
Alcohol consumption (yes)	3 (2.7%)	6 (6.1%)	0.310
Fecal occult blood (positive)	61 (61.6%)	38 (47.5%)	0.059
Granuloma detection rate	27 (25%)	31 (34.8%)	0.05
Montreal Fractal
Age (A2)	95 (83.3%)	79 (80.6%)	0.607
Location (L1)	35 (30.7%)	44 (45.8%)	0.032
Behavioral (B1)	67 (58.8%)	71 (72.4%)	0.037
Perianal lesions	38 (33.3%)	44 (45.8%)	0.067
Biological agent use	85 (74.6%)	66 (67.3%)	0.247

3.2. Laboratory tests

Fecal calprotectin (p = 0.001), ESR (p = 0.003), and CRP levels (p < 0.001) were significantly higher in patients with sarcopenia than in patients without sarcopenia. Hemoglobin (p < 0.001), and mean hemoglobin content (p < 0.001) and mean hemoglobin concentration (p = 0.002) levels in CD patients with sarcopenia were significantly lower and platelets (p = 0.008) and was significantly higher than those without sarcopenia.

In terms of coagulation indexes (Table 2), patients with sarcopenia had significantly higher levels of fibrinogen and fibrin degradation products, fibrinogen to albumin ratio (FAR) (p < 0.001), and slightly higher levels of prothrombin time, international normalized rate, prothrombin time activity and D-dimer than those patients without sarcopenia (p < 0.05). Serum total protein levels (p = 0.001), albumin levels (p < 0.001), albumin ratio (p < 0.001), and prealbumin level (p < 0.001) in patients with sarcopenia were significantly were lower than those patients without sarcopenia.

Table 2

Laboratory tests in CD patients with and without sarcopenia
Variables	Sarcopenia (n = 114)	Non-sarcopenia group (n = 98)	P-value
FC (µg/g)	948.9 (658.9,1279)	685.5 (291.9,1036.6)	0.001
ESR (mm/h)	35 (18,57)	23 (12,39)	0.003
CRP (mg/L)	24.3 (11.4,57.3)	10.3 (4.0,24.3)	< 0.001
FAR	0.123 ± 0.038	0.094 ± 0.030	< 0.001
NLR	3.48 (2.34,5.01)	3.08 (1.89,4.66)	0.094
Red blood cells (×10¹² /L)	4.47 ± 0.59	4.65 ± 0.57	0.027
Leukocytes (×10⁹ /L)	7.72 ± 3.3	7.14 ± 2.52	0.153
Hb(g/L)	116.5 ± 22.8	128.1 ± 21.0	< 0.001
Mean hemoglobin content (pg)	25.98 ± 3.31	27.54 ± 2.99	< 0.001
Mean hemoglobin concentration (g/L)	314.61 ± 15.46	320.83 ± 13.85	0.002
Neutrophils (×10⁹ /L)	4.98 (3.46,6.37)	4.12 (3.33,6.11)	0.192
Lymphocytes (×10⁹ /L)	1.41 (1.1,1.78)	1.45 (1.08,1.97)	0.496
Monocytes (×10⁹ /L)	0.6 (0.41,0.8)	0.51 (0.4,0.7)	0.065
Eosinophils (×10⁹ /L)	0.1 (0.07,0.18)	0.11 (0.06,0.2)	0.634
Basophils (×10⁹ /L)	0.02 (0,0.035)	0.02 (0,0.04)	0.443
Prothrombin time (s)	13.78 ± 0.87	13.36 ± 0.70	< 0.001
Prothrombin time activity (%)	13.83 ± 1.36	13.1 ± 1.37	< 0.001
Activated partial thromboplastin time (s)	42.04 ± 5.11	41.55 ± 6.05	0.547
Activated partial thromboplastin ratio	1.215 (1.12, 353)	1.205 (1.11, 1.368)	0.831
Fibrinogen (g/L)	4.47 ± 1.08	3.83 ± 0.96	< 0.001
Prothrombin time (s)	17.27 ± 1.45	17.39 ± 1.10	0.501
D-dimer (D-D) (mg/L)	0.345 (0.27, 0.55)	0.28 (0.22,0.377)	0.002
Fibrin degradation products (mg/L)	2.21 (1.89,3.02)	1.78 (1.473,2.355)	< 0.001
Plasma antithrombin (%)	92.43 ± 11.91	93.11 ± 11.89	0.703
Aspartate aminotransferase (U/L)	14 (10,17)	14 (12,18)	0.039
Alanine aminotransferase (U/L)	13 (8,18.25)	13 (9,19.25)	0.425
Total protein (g/L)	64.516 ± 7.730	67.987 ± 7.534	0.001
Albumin (g/L)	37.250 ± 5.816	41.329 ± 5.057	< 0.001
Globulin (g/L)	27.576 ± 5.291	26.665 ± 5.483	0.227
Albumin/globulin	1.390 ± 0.342	1.6248 ± 0.422	< 0.001
Prealbumin (mg/L)	128.92 ± 53.313	155.49 ± 52.766	< 0.001
Glucose (mmol/L)	4.28 (3.94, 4.82)	4.425 (4.07, 4.715)	0.396
Note: FC = fecal calprotectin, ESR = erythrocyte sedimentation rate, CRP = C-reactive protein, FAR = fibrinogen to albumin ratio, NLR = neutrophil to lymphocyte ratio, Hb = hemoglobin.

3.3. Logistic regression analysis

The associated factors for sarcopenia were further analyzed using one-way logistic regression. The parameters with statistically difference in Table 1 and Table 2 between the two groups were included in the one-way logistic regression. The results showed that simple ileal type (L1 type), non-stenotic non-penetrating type (B1 type), higher hemoglobin level, red blood cells, red blood cell ratio, mean red blood cell volume, mean hemoglobin content, mean hemoglobin concentration, higher prothrombin time activity, higher total blood protein, albumin, prealbumin, CRP, fecal calprotectin, erythrocyte distribution width, prothrombin time, fibrin, abdominal circumference (AC) and periumbilical subcutaneous fat thickness (SFT) were associated factors for sarcopenia in CD patients (Table 3).

Table 3

Associated factors for sarcopenia
Variable	Univariable logistic regression analysis		Multivariable logistic regression analysis
Variable	P value	OR value (95% CI)	P value	OR value (95% CI)
Gender (male/female)	0.696	1.128 (0.617–2.064)	0.086	0.447 (0.178–1.121)
Age (years)	0.155	0.983 (0.959–1.007)
L1-type	0.025	0.524 (0.297–0.922)	0.110	1.257 (0.949–1.665)
B1-type	0.038	0.542 (0.304–0.967)	0.222	1.414 (0.811–2.46)
Perianal lesions	0.468	0.817 (0.472–1.412)
FC (µg/g)	0.001	1.001 (1.000-1.002)	0.239	1.000 (1.000-1.001)
ESR (mm/h)	0.002	1.021 (1.008–1.034)
CRP (mg/L)	0.001	1.018 (1.008–1.029)	0.499	1.002 (0.997–1.007)
Hb (g/L)	0.000	0.976 (0.963–0.989)	0.034	0.978 (0.959–0.998)
PT(s)	< 0.001	2.070 (1.375–3.116)
PT(%)	< 0.001	0.961 (0.939–0.983)
FIbrinogen (g/L)	< 0.001	1.869 (1.377–2.536)	0.048	1.481 (1.004–2.184)
D-Dimer (mg/L)	0.714	1.092 (0.682–1.747)
FDP (mg/L)	0.138	1.187 (0.946–1.489)
TP (g/L)	0.002	0.941 (0.906–0.978)
Albumin (g/L)	< 0.001	0.872 (0.824–0.923)	0.023	0.922 (0.860–0.989)
A/G	< 0.001	0.189 (0.084–0.427)
Prealbumin (mg/L)	0.001	0.991 (0.985–0.996)	0.605	1.002 (0.994–1.010)
Note: A/G: albumin/globulin; CI = confidence interval; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; FC = fecal calprotectin; Hb = hemoglobin; FDP = Fibrinogen Degradation Products; NLR = neutrophil to lymphocyte ratio; PT = prothrombin time; TP = Thromboplastin;

The variables with p < 0.05 were next subjected to multivariable regression analysis after excluding parameters with strong correlations. Furthermore, despite gender was not statistically significant in the univariate analysis, we included gender in the multivariable analysis because gender may be related to other laboratory parameters. Gender, whether L1 type, whether B1 type, fecal calprotectin, CRP, hemoglobin, fibrinogen, albumin and prealbumin were finally included in the multivariable logistic regression analysis. The results showed that higher hemoglobin (OR:0.978; 95% CI: 0.963,0.989; p = 0.034) and serum albumin levels (OR: 0.922; 95% CI: 0.860,0.989; p = 0.023) were independent associated factors for sarcopenia in patients with CD, while higher fibrinogen levels (OR:1.481;95%CI:1.004,2.184; p = 0.048) was an independent risk factor for sarcopenia in patients with CD (Table 3).

3.4. Multivariate linear regression analysis

Subsequently, we discovered the link between SMI-L3 and Montreal location typing (L typing), the presence of mixed perianal lesions, CRP, fibrinogen, hemoglobin level, total serum protein levels using multiple linear regression analysis. The values of SMI-L3 were associated to patient gender, Montreal behavioral typing (B typing), hemoglobin, fibrinogen, and serum albumin levels (p < 0.05 or 0.01) (Table 4).

Table 4

Multivariate linear regression analysis of SMI-L3 in adult patients with Crohn's disease
variable	β	95%CI	P value
Gender (male/female)	-8.307	-10.690 to -5.924	< 0.001
L-type	-0.497	-1.266 to 0.272	0.204
B-type	-1.667	-3.282 to -0.052	0.043
Perianal lesions	-1.234	-3.145 to 0.677	0.204
CRP (mg/L)	0.001	-0.010 to 0.012	0.860
Hb (g/L)	0.091	0.038 to 0.144	0.001
FIbrinogen (g/L)	-1.033	-2.015 to -0.051	0.039
Albumin (g/L)	0.326	0.078 to 0.574	0.010
Note: CI = confidence interval; CRP = C-reactive protein; Hb = hemoglobin

3.5. The association between categorical Hb and prevalence of sarcopenia and SMI-L3

Next, we divided Hb into categorical data (IQR) and showed the association between categorical Hb and prevalence of sarcopenia and SMI-L3 (Table 5). SMI-L3 was increased with the increase of Hb levels in total population (p for trend < 0.001), men (p for trend < 0.001) and women (p for trend = 0.046). The prevalence of sarcopenia decreased with the increase of Hb levels in the in total population (p for trend = 0.006), men (p for trend = 0.004) and women (p for trend = 0.014).

Table 5

SMI-L3 and prevalence of sarcopenia in CD patients at different quartile levels of hemoglobin
Group (Hb)	Q1	Q2	Q3	Q4	P-trend
Sarcopenia
Total	69.1%	60.8%	47.2%	37.7%	0.006
Male	65.0%	68.4%	44.7%	32.4%	0.004
Female	65.4%	33.3%			0.014
SMI-L3(cm²/m²)
Total	33.94 ± 7.56	38.84 ± 6.81	44.11 ± 6.50	47.11 ± 7.13	< 0.001
Male	41.20 ± 7.41	42.29 ± 5.56	46.04 ± 6.06	48.02 ± 7.32	< 0.001
Female	30.88 ± 5.99	33.72 ± 4.49			0.046
Note: SMI-L3 = skeletal muscle index of lumbar spine 3

The aims of CD treatment is gradually shifting from the pursuit of clinical remission to patient-centered personalized management aspects[16]. CD with sarcopenia is gradually becoming a hot topic of research with the aim of achieving early screening, early intervention and prevention of adverse clinical outcomes. Malnutrition and a chronic inflammatory state may be major contributors to the development of sarcopenia in CD patients, and the severity of the disease itself may also be linked to this condition. Therefore, it is critical to identify patients who are at high risk for developing sarcopenia in clinical practice. In this study, we investigated the risk factors for sarcopenia in terms of a variety of clinical indicators. Our data showed that hemoglobin levels were associated with SMI-L3 and prevalence of sarcopenia. Intervention on low hemoglobin status may be a strategy for prevention of sarcopenia.

In this study, we observed that 53.8% (114/212 patients) of CD patients had sarcopenia. Two meta-analysis also summarized the prevalence of sarcopenia in CD patients. Bryant et al. Reported a prevalence of 51.2%[17]. Another study showed a prevalence of 46.2% [6]. Our result is consistent with those published data. Some studies also showed the associated factors for sarcopenia in CD patients [12, 18], such as nutrition-related indicators (Low Alb level) and higher levels of inflammatory markers (CRP, ESR, and FC). However, in a retrospective cohort study that included 76 patients undergoing CD surgery, CRP and Alb levels did not differ statistically between patients with and without sarcopenia [19]. Our study also showed that ALB level was an independent associated factor for sarcopenia. But no such associations were observed between CRP, FC and sarcopenia. It is hard to explain such differences. Different populations and different cutoff point were used in those studies which may be main reasons.

IBD patients frequently have anemia, which is related to the severity of the disease and is present in about two-thirds of patients at the time of initial diagnosis [20]. There are few researches examining the potential roles of Hb, a marker of anemia, in the sarcopenia in the IBD populations. Vinke et al.[21] found a significant correlation between Hb levels and reduced muscle mass and muscle strength in patients undergoing renal transplantation. According to a longitudinal study from Taiwan, China, Hb levels were independently linked to the onset of sarcopenia in an elderly population. The correlation between muscle function and sarcopenia was stronger in men and in people with higher basal burdens [13]. Our data showed that the prevalence of sarcopenia increased with the decrease of hemoglobin. Further, linear regression showed that Hb level was associated with SMI-L3. Moreover, mutivariable regression analysis after adjusting for inflammatory biomarkers also demonstrated that low hemoglobin level was associated with sarcopenia. Hb levels and sarcopenia may have a complicated and bidirectional relationship, with lower Hb levels indicating poorer nutritional status, malnutrition causing anemia and sarcopenia, and chronic sarcopenic depletion potentially further lowering Hb levels. Further research is necessary to determine whether the rise in Hb levels can prevent or even stop the development of sarcopenia.

How low Hb affect sarcopenia is not understood. The critical role of Hb is oxygen transport. It is well-known that oxygen is essential for the survival of cells. Low Hb may result in less oxygen delivery to cells or tissue. Consequently, chronic hypoxia may affect function or quality of tissues or organs [22]. A recent study also showed that low hemoglobin levels could cause poor muscle oxygenation, and induce low muscle mass and strength [23].

This study has several limitations. First, this was a retrospective single-center study and the sample size was relatively small because CD is not a common disease in China. Furthermore, we lacked clinical markers indicating the severity of the patients' illnesses. Additionally, we were unable to learn the specifics of the disease duration due to the non-specific character of the clinical signs of Crohn's disease. Further research is required to determine whether the severity and course of the disease are associated with sarcopenia. Lastly, sarcopenia was assessed based on CT or MRI, not based on dual-energy x-ray and bioelectrical impedance analysis (BIA). But lumbar muscle cross-sectional area by CT or MRI has also been used for sarcopenia evaluation [24].

In conclusion, the prevalence of sarcopenia increased with the decreasing of hemoglobin level. Hemoglobin level was positively associated with SMI-L3 and lower levels of Hb were independently associated with the development of sarcopenia in CD patients. Interventions targeting Hb may be a viable strategy to improve sarcopenia in CD patients.

abdominal circumference

APTT

activated partial thromboplastin time

Crohn's Disease

confidence interval

CRP

C-reactive protein

computed tomography

ESR

erythrocyte sedimentation rate

FAR

fibrinogen to albumin ratio

fecal calprotectin

FDP

fibrin (pro) degradation product

FIB

fibrinogen

hemoglobin

MRI

magnetic resonance imaging

NLR

neutrophil to lymphocyte ratio

odds ratio

prothrombin time

SFT

periumbilical subcutaneous fat thickness

Acknowledgement

None

Author Contributions

XC contributed to the study design, interpretation and analysis of the data, and review of the manuscript. NH, JL, HT, XG, JW, ZW, ZW and XC contributed to the collection of data. NH, JL, HT, and XC contributed to the interpretation and analysis of the data, and writing of the manuscript. All authors approved the final manuscript.

Availability of data and materials

All data generated or analyzed during this study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the Affiliated Hospital of Nanjing University of Chinese Medicine. And informed consent was waived because of the retrospective design.

Consent for publication

Not applicable.

Competing Interests

None

Funding

This study This study was received supports from National Natural Science Foundation of China (No. 81773460) and Foundation of Jiangsu Provincial Hospital of Chinese Medicine

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No competing interests reported.

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The association between hemoglobin level and sarcopenia in patients with Crohn's disease

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Abstract

Figures

1. Introduction

2. Materials and methods

2.1. Study Participants

2.2. Data collection of Crohn's disease patients

2.3. CTE or MRE imaging

2.4. Definition of sarcopenia in Crohn's patients

2.5. Statistical analysis

3. Results

3.1.General information

3.2. Laboratory tests

3.3. Logistic regression analysis

3.4. Multivariate linear regression analysis

3.5. The association between categorical Hb and prevalence of sarcopenia and SMI-L3

Discussion

Abbreviations

Declarations

References

Additional Declarations

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