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Terbah R, Testro A, Gow P, Majumdar A, Sinclair M. Portal Hypertension in Malnutrition and Sarcopenia in Decompensated Cirrhosis-Pathogenesis, Implications and Therapeutic Opportunities. Nutrients 2023; 16:35. [PMID: 38201864 PMCID: PMC10780673 DOI: 10.3390/nu16010035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
Malnutrition and sarcopenia are highly prevalent in patients with decompensated cirrhosis and are associated with poorer clinical outcomes. Their pathophysiology is complex and multifactorial, with protein-calorie malnutrition, systemic inflammation, reduced glycogen stores and hormonal imbalances all well reported. The direct contribution of portal hypertension to these driving factors is however not widely documented in the literature. This review details the specific mechanisms by which portal hypertension directly contributes to the development of malnutrition and sarcopenia in cirrhosis. We summarise the existing literature describing treatment strategies that specifically aim to reduce portal pressures and their impact on nutritional and muscle outcomes, which is particularly relevant to those with end-stage disease awaiting liver transplantation.
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Affiliation(s)
- Ryma Terbah
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Adam Testro
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Avik Majumdar
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
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Yap KY, Chi H, Ng S, Ng DHL, Shelat VG. Effect of perioperative branched chain amino acids supplementation in liver cancer patients undergoing surgical intervention: A systematic review. World J Gastrointest Surg 2023; 15:2596-2618. [PMID: 38111761 PMCID: PMC10725538 DOI: 10.4240/wjgs.v15.i11.2596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/15/2023] [Accepted: 10/23/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Branched chain amino acid (BCAA) supplementation has been associated with favourable outcomes in liver malignancies requiring definitive resection or liver transplantation. Currently, there are no updated systematic reviews evaluating the efficacy of perioperative BCAA supplementation in patients undergoing surgery for liver cancer. AIM To evaluate the efficacy of perioperative BCAA supplementation in patients undergoing surgery for liver cancer. METHODS A systematic review of randomized control trials and observational studies was conducted on PubMed, Embase, Cochrane Library, Scopus, and Web of Science to evaluate the effect of perioperative BCAA supplementation compared to standard in-hospital diet, in liver cancer patients undergoing surgery. Clinical outcomes were extracted, and a meta-analysis was performed on relevant outcomes. RESULTS 16 studies including 1389 patients were included. Perioperative BCAA administration was associated with reduced postoperative infection [risk ratio (RR) = 0.58 95% confidence intervals (CI): 0.39 to 0.84, P = 0.005] and ascites [RR = 0.57 (95%CI: 0.38 to 0.85), P = 0.005]. There was also a reduction in length of hospital stay (LOS) [weighted mean difference (WMD) = -3.03 d (95%CI: -5.49 to -0.57), P = 0.02] and increase in body weight [WMD = 1.98 kg (95%CI: 0.35 to 3.61, P = 0.02]. No significant differences were found in mortality, cancer recurrence and overall survival. No significant safety concerns were identified. CONCLUSION Perioperative BCAA administration is efficacious in reducing postoperative infection, ascites, LOS, and increases body weight in liver cancer patients undergoing surgical resection.
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Affiliation(s)
- Kwan Yi Yap
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - HongHui Chi
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Sherryl Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Doris HL Ng
- Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 636921, Singapore
| | - Vishal G Shelat
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 636921, Singapore
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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Tajima T, Hata K, Haga H, Kusakabe J, Kageyama S, Yurugi K, Hishida R, Zhao X, Nishikori M, Nagao M, Takaori-Kondo A, Uemoto S, Hatano E. Risk factors for antibody-mediated rejection in ABO blood-type incompatible and donor-specific antibody-positive liver transplantation. Liver Transpl 2023; 29:711-723. [PMID: 36749821 DOI: 10.1097/lvt.0000000000000084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/07/2023] [Indexed: 02/09/2023]
Abstract
Antibody-mediated rejection (AMR) is a refractory rejection after ABO blood-type incompatible (ABOi) or donor-specific antibody (DSA)-positive liver transplantation (LT). Pretransplant rituximab desensitization dramatically reduced posttransplant AMR development; however, risk factors for AMR in the rituximab era remain unclear in both ABOi living-donor LT (ABOi-LDLT) and preformed DSA-positive LT (pDSA-LT). Of our 596 adult LDLTs (≥18 y) after rituximab introduction (2004-2019), 136 were ABOi-LDLT (22.8%). After excluding retransplants (9), acute liver failure (7), and protocol deviations (16), 104 ABOi-LDLTs were finally enrolled. Of these, 19 recipients developed AMR, 18 of which occurred within 2 weeks after transplantation (95%). ABOi-AMR significantly worsened graft and recipient survival than those without ( p =0.02 and 0.04, respectively). Model for End-stage Liver Disease (MELD) ≤13 (OR: 5.15 [1.63-16.3], p =0.005) and pre-rituximab anti-ABO IgM-titer ≥128 (OR: 3.25 [1.05-10.0], p =0.03) were identified as independent risk factors for ABOi-AMR development. Recipients fulfilling both factors showed significantly worse survival rates than those who did not ( p =0.003). Of 352 adult LTs, after introducing the LABScreen Single Ag method (2009-2019), pDSA with mean fluorescence intensity (MFI) ≥500 was detected in 50 cases (14.2%). After excluding 10 ABOi-LDLTs, 40 pDSA-LTs were finally analyzed, of which 5 developed AMR. The combination of high-titer (sum-MFI ≥10,000) and multi-loci pDSAs was a significant risk factor for pDSA-AMR development ( p <0.001); however, it did not affect the 5-year recipient survival compared with those without ( p =0.56). In conclusion, preoperative MELD ≤13 and pre-rituximab anti-ABO IgM-titer ≥128 for ABOi-LDLT, and the combination of sum-MFI ≥10,000 and multi-loci pDSAs for pDSA-LT, are risk factors for AMR in the era of rituximab desensitization. Characteristically, ABOi-AMR significantly deteriorated graft and recipient survival, whereas pDSA-AMR did not.
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Affiliation(s)
- Tetsuya Tajima
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koichiro Hata
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hironori Haga
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | - Jiro Kusakabe
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shoichi Kageyama
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kimiko Yurugi
- Department of Clinical Laboratory Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Rie Hishida
- Department of Clinical Laboratory Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Xiangdong Zhao
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Momoko Nishikori
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Miki Nagao
- Department of Clinical Laboratory Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Shiga University of Medical Science, Otsu, Japan
| | - Etsuro Hatano
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Ravaioli F, De Maria N, Di Marco L, Pivetti A, Casciola R, Ceraso C, Frassanito G, Pambianco M, Pecchini M, Sicuro C, Leoni L, Di Sandro S, Magistri P, Menozzi R, Di Benedetto F, Colecchia A. From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients. Nutrients 2023; 15:2778. [PMID: 37375682 DOI: 10.3390/nu15122778] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/04/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Liver transplantation (LT) is a complex surgical procedure requiring thorough pre- and post-operative planning and care. The nutritional status of the patient before, during, and after LT is crucial to surgical success and long-term prognosis. This review aims to assess nutritional status assessment and management before, during, and after LT, with a focus on patients who have undergone bariatric surgery. We performed a comprehensive topic search on MEDLINE, Ovid, In-Process, Cochrane Library, EMBASE, and PubMed up to March 2023. It identifies key factors influencing the nutritional status of liver transplant patients, such as pre-existing malnutrition, the type and severity of liver disease, comorbidities, and immunosuppressive medications. The review highlights the importance of pre-operative nutritional assessment and intervention, close nutritional status monitoring, individualised nutrition care plans, and ongoing nutritional support and monitoring after LT. The review concludes by examining the effect of bariatric surgery on the nutritional status of liver transplant recipients. The review offers valuable insights into the challenges and opportunities for optimising nutritional status before, during, and after LT.
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Affiliation(s)
- Federico Ravaioli
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Nicola De Maria
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Lorenza Di Marco
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Alessandra Pivetti
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Riccardo Casciola
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Carlo Ceraso
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Gabriella Frassanito
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Martina Pambianco
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Maddalena Pecchini
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Chiara Sicuro
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Laura Leoni
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Renata Menozzi
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Antonio Colecchia
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
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Trigui A, Rose CF, Bémeur C. Nutritional Strategies to Manage Malnutrition and Sarcopenia following Liver Transplantation: A Narrative Review. Nutrients 2023; 15:nu15040903. [PMID: 36839261 PMCID: PMC9965211 DOI: 10.3390/nu15040903] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/17/2023] Open
Abstract
Persisting or newly developed malnutrition and sarcopenia after liver transplant (LT) are correlated with adverse health outcomes. This narrative review aims to examine the literature regarding nutrition strategies to manage malnutrition and sarcopenia after LT. The secondary aims are to provide an overview of the effect of nutrition strategies on the incidence of infections, hospital length of stay (LOS), acute cellular rejection (ACR), and mortality after LT. Four databases were searched. A total of 25 studies, mostly of mid-high quality, were included. Six studies found a beneficial effect on nutritional parameters using branched-chain amino acids (BCAA), immunomodulating diet (IMD), or enteral nutrition (EN) whereas two studies using beta-hydroxy-beta-methylbutyrate (HMB) found a beneficial effect on muscle mass and function. Fourteen studies using pre- or pro-biotics, IMD, and EN were effective in lowering infection and six studies using IMD, BCAA or HMB reported reduced hospital LOS. Finally, four studies using HMB and vitamin D were effective in reducing ACR and one study reported reduced mortality using vitamin D after LT. In conclusion, nutritional intervention after LT has different beneficial effects on malnutrition, sarcopenia, and other advert outcomes. Additional large and well-constructed RCTs using validated tools to assess nutritional status and sarcopenia are warranted to ensure more robust conclusions.
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Affiliation(s)
- Amal Trigui
- Department of Nutrition, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1A8, Canada
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, QC H2X 0A9, Canada
| | - Christopher F. Rose
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, QC H2X 0A9, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada
| | - Chantal Bémeur
- Department of Nutrition, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1A8, Canada
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montreal, QC H2X 0A9, Canada
- Correspondence: ; Tel.: +1-5148908000 (ext. 23607)
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Lovesley D, John S, Khakhar A, Ramakrishnan B, Ramamurthy A. Handgrip strength: A simple and effective tool to predict mortality after liver transplantation. Clin Nutr ESPEN 2022; 51:323-335. [DOI: 10.1016/j.clnesp.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 05/26/2022] [Accepted: 08/07/2022] [Indexed: 10/15/2022]
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Reshetnyak VI, Maev IV. Mechanism for development of malnutrition in primary biliary cholangitis. World J Meta-Anal 2022. [DOI: 10.13105/wjma.v10.i3.81 reshetnyak vi] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
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Reshetnyak VI, Maev IV. Mechanism for development of malnutrition in primary biliary cholangitis. World J Meta-Anal 2022; 10:81-98. [DOI: 10.13105/wjma.v10.i3.81] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/14/2022] [Accepted: 05/23/2022] [Indexed: 02/06/2023] Open
Abstract
Primary biliary cholangitis (PBC) is a chronic cholestatic liver disease that is associated with impaired biliary excretion processes. Along with the development of cholestasis, there is a deficient flow of bile acids into the intestinal lumen causing malnutrition (MN) that is manifested in deficiencies of both macro- and micronutrients. The mechanism for development of trophological insufficiency is multifactorial. However, the trigger of MN in PBC is impaired enterohepatic circulation of bile acids. The ingress of bile acids with a detergent effect into the general bloodstream, followed by elimination via the kidneys and skin, triggers a cascade of metabolic disturbances, which leads to the gradual development and progression of calorie MN. The latter gradually transforms into protein-calorie MN (PСM) (as marasmus) due to the insufficient entry of bile acids into the duodenum, which is accompanied by a decrease in the emulsification, hydrolysis, and absorption of fats and fat-soluble vitamins, as well as disturbance of intestinal motility and bacterial overgrowth. Fat-soluble vitamin deficiencies complement PСM with vitamin and mineral MN. The development of hepatocellular failure enhances the progression of PСM due to the impaired protein synthetic function of hepatocytes in the advanced stage of PBC, which results in deficiency of not only the somatic but also the visceral pool of proteins. A mixed PСM form of marasmus and kwashiorkor develops. Early recognition of energy, protein, micronutrient, and macronutrient deficiencies is of great importance because timely nutritional support can improve liver function and quality of life in patients with PBC. In this case, it is important to know what type (energy, protein-calorie, vitamin, and vitamin-mineral) and form (marasmus, marasmus-kwashiorkor) of MN is present in the patient and how it is associated with the stage of the disease. Therefore, it is recommended to screen all patients with PBC for MN, from the early asymptomatic stage of the disease in order to identify and avoid preventable complications, such as fatigue, malaise, performance decrement, sarcopenia, osteoporosis, and hepatic encephalopathy, which will be able to provide appropriate nutritional support for correction of the trophological status.
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Affiliation(s)
- Vasiliy Ivanovich Reshetnyak
- Department of Propaedeutic of Internal Diseases and Gastroenterology, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow 127473, Russia
| | - Igor Veniaminovich Maev
- Department of Propaedeutic of Internal Diseases and Gastroenterology, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow 127473, Russia
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Ferreira S, Marroni CA, Stein JT, Rayn R, Henz AC, Schmidt NP, Carteri RB, Fernandes SA. Assessment of resting energy expenditure in patients with cirrhosis. World J Hepatol 2022; 14:802-811. [PMID: 35646265 PMCID: PMC9099101 DOI: 10.4254/wjh.v14.i4.802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/13/2022] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Malnutrition affects 20% to 50% of patients with cirrhosis. It may be associated with serious complications and has a direct impact on prognosis. Resting energy expenditure (REE) is an important parameter to guide the optimization of therapy and recovery of nutritional status in patients with cirrhosis. However, the REE of patients with cirrhosis is still unclear, casting doubt upon the optimal nutritional management approach.
AIM To identify the best method that predicts the REE of cirrhotic patients, using indirect calorimetry (IC) as the gold standard.
METHODS An observational study was performed on 90 patients with cirrhosis. REE was assessed by IC, bioelectrical impedance analysis (BIA), and predictive formulas, which were compared using Bland-Altman plots and the Student’s t-test.
RESULTS REE values measured by IC (1607.72 ± 257.4 kcal) differed significantly from those determined by all other methods (BIA: 1790.48 ± 352.1 kcal; Harris & Benedict equation: 2373.54 ± 254.9 kcal; IOM equation: 1648.95 ± 185.6 kcal; Cunningham equation: 1764.29 ± 246.2 kcal), except the Food and Agriculture Organization of the United Nations, World Health Organization, and United Nations University (FAO/WHO/UNU) (1616.07 ± 214.6 kcal) and McArdle (1611.30 ± 241.8 kcal) equations. We found no significant association when comparing IC and 24-h dietary recall among different Child-Pugh classes of cirrhosis.
CONCLUSION The IOM and FAO/WHO/UNU equations have the best agreement with the CI. These results indicate a possibility of different tools for the clinical practice on cirrhotic patients.
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Affiliation(s)
- Shaiane Ferreira
- Postgraduate Program in Hepatology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
| | - Cláudio Augusto Marroni
- Postgraduate Program in Hepatology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
| | - Jessica Taina Stein
- Postgraduate Program in Hepatology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
| | - Roberta Rayn
- Postgraduate Program in Hepatology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
| | - Ana Cristhina Henz
- Postgraduate Program in Hepatology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
| | - Natália P Schmidt
- Postgraduate Program in Hepatology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
| | - Randhall B Carteri
- Department of Nutrition, Centro Universitário Metodista - IPA, Porto Alegre 90420-060, Brazil
- Department of Health and Behavior, Catholic University of Pelotas, Pelotas 96015-560, Brazil
| | - Sabrina Alves Fernandes
- Postgraduate Program in Hepatology, Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre 90050-170, Brazil
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Lee DU, Fan GH, Hastie DJ, Addonizio EA, Prakasam VN, Ahern RR, Seog KJ, Karagozian R. The Impact of Malnutrition on the Hospital and Infectious Outcomes of Patients Admitted With Alcoholic Hepatitis: 2011 to 2017 Analysis of US Hospitals. J Clin Gastroenterol 2022; 56:349-359. [PMID: 33769393 DOI: 10.1097/mcg.0000000000001528] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/06/2021] [Indexed: 01/13/2023]
Abstract
GOALS We specifically evaluate the effect of malnutrition on the infection risks of patients admitted with alcoholic hepatitis using a national registry of hospitalized patients in the United States. BACKGROUND Malnutrition is a common manifestation of alcoholic hepatitis that affects patient outcomes. STUDY 2011 to 2017 National Inpatient Sample was used to isolated patients with alcoholic hepatitis, stratified using malnutrition (protein-calorie malnutrition, sarcopenia, and weight loss/cachexia) and matched using age, gender, and race with 1:1 nearest neighbor matching method. Endpoints included mortality and infectious endpoints. RESULTS After matching, there were 10,520 with malnutrition and 10,520 malnutrition-absent controls. Mortality was higher in the malnutrition cohort [5.02 vs. 2.29%, P<0.001, odds ratio (OR): 2.25, 95% confidence interval (CI): 1.93-2.63], as were sepsis (14.2 vs. 5.46, P<0.001, OR: 2.87, 95% CI: 2.60-3.18), pneumonia (10.9 vs. 4.63%, P<0.001, OR: 2.51, 95% CI: 2.25-2.81), urinary tract infection (14.8 vs. 9.01%, P<0.001, OR: 1.76, 95% CI: 1.61-1.91), cellulitis (3.17 vs. 2.18%, P<0.001, OR: 1.47, 95% CI: 1.24-1.74), cholangitis (0.52 vs. 0.20%, P<0.001, OR: 2.63, 95% CI: 1.59-4.35), and Clostridium difficile infection (1.67 vs. 0.91%, P<0.001, OR: 1.85, 95% CI: 1.44-2.37). In multivariate models, malnutrition was associated with mortality [P<0.001, adjusted odds ratio (aOR): 1.61, 95% CI: 1.37-1.90] and infectious endpoints: sepsis (P<0.001, aOR: 2.42, 95% CI: 2.18-2.69), pneumonia (P<0.001, aOR: 2.19, 95% CI: 1.96-2.46), urinary tract infection (P<0.001, aOR: 1.68, 95% CI: 1.53-1.84), cellulitis (P<0.001, aOR: 1.46, 95% CI: 1.22-1.74), cholangitis (P=0.002, aOR: 2.27, 95% CI: 1.36-3.80), and C. difficile infection (P<0.001, aOR: 1.89, 95% CI: 1.46-2.44). CONCLUSION This study shows the presence of malnutrition is an independent risk factor of mortality and local/systemic infections in patients admitted with alcoholic hepatitis.
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Affiliation(s)
- David U Lee
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Washington Street, Boston, MA
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Çınar F, Bulbuloglu S. The effect of adherence to immunosuppressant therapy on gastrointestinal complications after liver transplantation. Transpl Immunol 2022; 71:101554. [DOI: 10.1016/j.trim.2022.101554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/10/2022] [Accepted: 02/10/2022] [Indexed: 11/30/2022]
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Malnutrition and low muscle strength are independent predictors of clinical outcomes and healthcare costs after liver transplant. Clin Nutr ESPEN 2022; 48:210-219. [DOI: 10.1016/j.clnesp.2022.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/14/2022] [Indexed: 11/21/2022]
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Ruiz-Margáin A, Román-Calleja BM, Moreno-Guillén P, González-Regueiro JA, Kúsulas-Delint D, Campos-Murguía A, Flores-García NC, Macías-Rodríguez RU. Nutritional therapy for hepatocellular carcinoma. World J Gastrointest Oncol 2021; 13:1440-1452. [PMID: 34721776 PMCID: PMC8529929 DOI: 10.4251/wjgo.v13.i10.1440] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/23/2021] [Accepted: 08/09/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the most frequent primary liver cancer and presents together with cirrhosis in most cases. In addition to commonly recognized risk factors for HCC development, such as hepatitis B virus/hepatitis C virus infection, age and alcohol/tobacco consumption, there are nutritional risk factors also related to HCC development including high intake of saturated fats derived from red meat, type of cooking (generation of heterocyclic amines) and contamination of foods with aflatoxins. On the contrary, protective nutritional factors include diets rich in fiber, fruits and vegetables, n-3 polyunsaturated fatty acids and coffee. While the patient is being evaluated for staging and treatment of HCC, special attention should be paid to nutritional support, including proper nutritional assessment and therapy by a multidisciplinary team. It must be considered that these patients usually develop HCC on top of long-lasting cirrhosis, and therefore they could present with severe malnutrition. Cirrhosis-related complications should be properly addressed and considered for nutritional care. In addition to traditional methods, functional testing, phase angle and computed tomography scan derived skeletal muscle index-L3 are among the most useful tools for nutritional assessment. Nutritional therapy should be centered on providing enough energy and protein to manage the increased requirements of both cirrhosis and cancer. Supplementation with branched-chain amino acids is also recommended as it improves response to treatment, nutritional status and survival, and finally physical exercise must be encouraged and adapted to individual needs.
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Affiliation(s)
- Astrid Ruiz-Margáin
- Liver Nutrition Clinic, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Liver Fibrosis and Nutrition Lab, MICTLÁN-Network (Mechanisms of Liver Injury, Cell Death and Translational Nutrition in Liver Diseases- Research Network), Mexico City 14080, Mexico
| | - Berenice M Román-Calleja
- Liver Nutrition Clinic, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Paulina Moreno-Guillén
- Liver Nutrition Clinic, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - José A González-Regueiro
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Deyanira Kúsulas-Delint
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Alejandro Campos-Murguía
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Nayelli C Flores-García
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Ricardo Ulises Macías-Rodríguez
- Liver Fibrosis and Nutrition Lab, MICTLÁN-Network (Mechanisms of Liver Injury, Cell Death and Translational Nutrition in Liver Diseases- Research Network), Mexico City 14080, Mexico
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
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Tessitore M, Sorrentino E, Schiano Di Cola G, Colucci A, Vajro P, Mandato C. Malnutrition in Pediatric Chronic Cholestatic Disease: An Up-to-Date Overview. Nutrients 2021; 13:2785. [PMID: 34444944 PMCID: PMC8400766 DOI: 10.3390/nu13082785] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/08/2021] [Accepted: 08/11/2021] [Indexed: 12/16/2022] Open
Abstract
Despite recent advances, the causes of and effective therapies for pediatric chronic cholestatic diseases remain elusive, and many patients progress to liver failure and need liver transplantation. Malnutrition is a common complication in these patients and is a well-recognized, tremendous challenge for the clinician. We undertook a narrative review of both recent and relevant older literature, published during the last 20 years, for studies linking nutrition to pediatric chronic cholestasis. The collected data confirm that malnutrition and failure to thrive are associated with increased risks of morbidity and mortality, and they also affect the outcomes of liver transplantation, including long-term survival. Malnutrition in children with chronic liver disease is multifactorial and with multiple potential nutritional deficiencies. To improve life expectancy and the quality of life, patients require careful assessments and appropriate management of their nutritional statuses by multidisciplinary teams, which can identify and/or prevent specific deficiencies and initiate appropriate interventions. Solutions available for the clinical management of these children in general, as well as those directed to specific etiologies, are summarized. We particularly focus on fat-soluble vitamin deficiency and malnutrition due to fat malabsorption. Supplemental feeding, including medium-chain triglycerides, essential fatty acids, branched-chain amino acids, and the extra calories needed to overcome the consequences of anorexia and high energy requirements, is reviewed. Future studies should address the need for further improving commercially available and nutritionally complete infant milk formulae for the dietary management of this fragile category of patients. The aid of a specialist dietitian, educational training regarding nutritional guidelines for stakeholders, and improving family nutritional health literacy appear essential.
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Affiliation(s)
- Maria Tessitore
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Chair of Pediatrics and Residency Program of Pediatrics, Via S. Allende, University of Salerno, 84081 Baronissi, SA, Italy; (M.T.); (E.S.); (G.S.D.C.); (A.C.); (P.V.)
| | - Eduardo Sorrentino
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Chair of Pediatrics and Residency Program of Pediatrics, Via S. Allende, University of Salerno, 84081 Baronissi, SA, Italy; (M.T.); (E.S.); (G.S.D.C.); (A.C.); (P.V.)
| | - Giuseppe Schiano Di Cola
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Chair of Pediatrics and Residency Program of Pediatrics, Via S. Allende, University of Salerno, 84081 Baronissi, SA, Italy; (M.T.); (E.S.); (G.S.D.C.); (A.C.); (P.V.)
| | - Angelo Colucci
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Chair of Pediatrics and Residency Program of Pediatrics, Via S. Allende, University of Salerno, 84081 Baronissi, SA, Italy; (M.T.); (E.S.); (G.S.D.C.); (A.C.); (P.V.)
| | - Pietro Vajro
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Chair of Pediatrics and Residency Program of Pediatrics, Via S. Allende, University of Salerno, 84081 Baronissi, SA, Italy; (M.T.); (E.S.); (G.S.D.C.); (A.C.); (P.V.)
| | - Claudia Mandato
- Department of Pediatrics, Santobono-Pausilipon Children’s Hospital Via M. Fiore, 80129 Naples, Italy
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Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale RG, Waitzberg D, Bischoff SC, Singer P. ESPEN practical guideline: Clinical nutrition in surgery. Clin Nutr 2021; 40:4745-4761. [PMID: 34242915 DOI: 10.1016/j.clnu.2021.03.031] [Citation(s) in RCA: 194] [Impact Index Per Article: 64.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 02/07/2023]
Abstract
Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.
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Affiliation(s)
- Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany.
| | - Marco Braga
- University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Franco Carli
- Department of Anesthesia of McGill University, School of Nutrition, Montreal General Hospital, Montreal, Canada
| | | | - Martin Hübner
- Service de chirurgie viscérale, Centre Hospitalier Universitaire de Lausanne, Lausanne, Switzerland
| | - Stanislaw Klek
- General Surgical Oncology Clinic, National Cancer Institute, Krakow, Poland
| | - Alessandro Laviano
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
| | | | - Dan Waitzberg
- University of Sao Paulo Medical School, Ganep, Human Nutrition, Sao Paulo, Brazil
| | - Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany
| | - Pierre Singer
- Institute for Nutrition Research, Rabin Medical Center, Beilison Hospital, Petah Tikva, Israel
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17
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Duong N, Sadowski B, Rangnekar AS. The Impact of Frailty, Sarcopenia, and Malnutrition on Liver Transplant Outcomes. Clin Liver Dis (Hoboken) 2021; 17:271-276. [PMID: 33968388 PMCID: PMC8087926 DOI: 10.1002/cld.1043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/13/2020] [Accepted: 09/20/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Nikki Duong
- Department of Internal MedicineMedStar Georgetown University HospitalWashingtonDC
- Division of Gastroenterology, Hepatology, and NutritionVirginia Commonwealth UniversityRichmondVA
- MedStar Georgetown Transplant InstituteGeorgetown University HospitalWashingtonDC
| | - Brett Sadowski
- MedStar Georgetown Transplant InstituteGeorgetown University HospitalWashingtonDC
| | - Amol S. Rangnekar
- MedStar Georgetown Transplant InstituteGeorgetown University HospitalWashingtonDC
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Chiang RS, Parish A, Niedzwiecki D, Kappus MR, Muir AJ. Impact of Malnutrition on Outcomes in Patients Undergoing Transjugular Intrahepatic Portosystemic Shunt Insertion. Dig Dis Sci 2020; 65:3332-3340. [PMID: 31965391 DOI: 10.1007/s10620-019-06038-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/30/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND Malnutrition is common in patients with cirrhosis and is associated with poor outcomes after hepatic resection and liver transplantation. Transjugular intrahepatic portosystemic shunt (TIPS) is performed for complications of cirrhosis. AIM To assess the impact of malnutrition on TIPS outcomes. METHODS A retrospective analysis was performed using the Healthcare Cost and Utilization Project: National Inpatient Sample database for TIPS procedures from 2005 to 2014. The primary end point was in-hospital mortality. The association of specific malnutrition diagnostic codes and race-ethnicity on mortality was evaluated with survey-weighted logistic regression adjusted for age, gender, admission type, insurance payer, hospital region, comorbidities, and length of stay (LOS). RESULTS From 2005 to 2014, an estimated 53,207 (95% CI 49,330-57,085) admissions with TIPS occurred. A diagnosis of malnutrition was present in 11%. In-hospital death post-TIPS occurred in 15.0% versus 10.7% (p value < 0.001) of patients with and without malnutrition, respectively. Patients with malnutrition had longer post-procedural LOS (median 6.7 vs. 2.9 days, p value < 0.001) and greater total hospital charges (median $144,752 vs. $79,781, p value < 0.001) and were more likely to be discharged to a skilled nursing facility (21.6% vs. 9.7%) than patients without malnutrition. Patients with malnutrition had increased odds of mortality (OR 1.31, 95% CI 1.07, 1.59) compared to patients with no malnutrition. CONCLUSION Malnutrition was associated with worse outcomes after TIPS. Further research is needed to understand the mechanism of malnutrition in post-procedure outcomes and the ability of interventions for nutritional optimization to improve outcomes.
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Affiliation(s)
- Ryan S Chiang
- Duke University School of Medicine, 2530 Erwin Road APT 254, Durham, NC, 27705, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, DUMC 2721, Durham, NC, 27710, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, DUMC 2721, Durham, NC, 27710, USA.,Duke Cancer Institute-Biostatistics, Hock Plaza I, 2424 Erwin Rd, Suite 802, Room 8040, Durham, NC, 27705, USA
| | - Matthew R Kappus
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC 3923, Durham, NC, 27710, USA
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, DUMC 3923, Durham, NC, 27710, USA. .,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
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Bischoff SC, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, Plauth M. ESPEN practical guideline: Clinical nutrition in liver disease. Clin Nutr 2020; 39:3533-3562. [PMID: 33213977 DOI: 10.1016/j.clnu.2020.09.001] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Practical guideline is based on the current scientific ESPEN guideline on Clinical Nutrition in Liver Disease. METHODS It has been shortened and transformed into flow charts for easier use in clinical practice. The guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with chronic liver disease. RESULTS A total of 103 statements and recommendations are presented with short commentaries for the nutritional and metabolic management of patients with (i) acute liver failure, (ii) alcoholic steatohepatitis, (iii) non-alcoholic fatty liver disease, (iv) liver cirrhosis, and (v) liver surgery/transplantation. The disease-related recommendations are preceded by general recommendations on the diagnostics of nutritional status in liver patients and on liver complications associated with medical nutrition. CONCLUSION This practical guideline gives guidance to health care providers involved in the management of liver disease to offer optimal nutritional care.
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Affiliation(s)
- Stephan C Bischoff
- Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany.
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Lindsay D Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Tatjana Schütz
- IFB Adiposity Diseases, Leipzig University Medical Centre, Leipzig, Germany
| | - Mathias Plauth
- Department of Internal Medicine, Municipal Hospital of Dessau, Dessau, Germany
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Abstract
BACKGROUND AND AIM Body composition has emerged as a prognostic factor for end-stage liver disease. We therefore investigated muscle mass, body fat and other clinical-pathological variables as predictors of posttransplant survival. METHODS A total of 368 patients, who underwent orthotopic liver transplantation (OLT) at our institution, were assessed prior to OLT and followed for a median of 9.0 years (range 2.0-10.0 years) after OLT. Psoas, erector spinae and the combined paraspinal muscle area, as well as the corresponding indices normalized by body-height squared, were quantified by a lumbar (L3) cross-sectional computed tomography. In addition, absolute body fat and bone density were estimated by the same computed tomography approach. RESULTS Paraspinal muscle index (PSMI) (hazard ratio 0.955, P = 0.039) and hepatitis C (hazard rati 1.498, P = 0.038) were independently associated with post-OLT mortality. In contrast, body fat and bone density did not significantly affect post-OLT outcome (P > 0.05). The PSMI also predicted one-year posttransplant mortality with a receiver operating characteristics-area under the curve of 0.671 [95% confidence interval (CI) 0.589-0.753, P < 0.001) in male patients and outperformed individual psoas and erector spinae muscle group assessments in this regard. In male patients, a defined PSMI cutoff (<18.41 cm/m) was identified as suitable determinant for sarcopenia and posttransplant one-year mortality. In female OLT-recipients, however, sarcopenia was not predictive for patient survival und a women-specific cutoff could not be derived from this study. CONCLUSIONS Taken together this analysis provides evidence, which PSMI is a relevant marker for muscle mass and that sarcopenia is an independent predictor of early post-OLT survival in male patients.
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Kamo N, Kaido T, Miyachi Y, Iwamura S, Yao S, Shirai H, Yagi S, Uemoto S. Preoperative abnormal body composition is closely related to bacteremia after living donor liver transplantation. Nutrition 2020; 77:110798. [PMID: 32446184 DOI: 10.1016/j.nut.2020.110798] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/01/2020] [Accepted: 02/13/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Infection is the most critical cause of early death after liver transplantation (LT). However, the effect of preoperative body composition on bacteremia after LT is unclear. The aim of this study was to examine the effects of preoperative body composition on bacteremia after living donor LT (LDLT). METHODS The study comprised 277 patients who underwent LDLT at Kyoto University, Kyoto, Japan, between January 2008 and June 2016. We evaluated body composition parameters including skeletal muscle mass index (SMI), intramuscular adipose tissue content (IMAC), and visceral-to-subcutaneous adipose tissue area ratio (VSR) using preoperative plain computed tomography at the L3 level. We compared the incidence of bacteremia, species, period of antibiotic administration, mortality due to bacteremia, and survival rates according to the number of abnormal body composition factors (low SMI, high IMAC, and high VSR). Moreover, risk factors for post-transplant bacteremia were examined. RESULTS Incidence of bacteremia was significantly higher in patients with three abnormal factors (47.1%), two factors (42%), or a single factor (37%) than in patients with no factors (22.5%; P = 0.027). Species of bacteremia did not differ significantly among the four groups. The period of antibiotic administration was significantly shorter (P = 0.039) and mortality of patients with bacteremia and survival rates were significantly better (P < 0.001, each) in patients with no factors. Multivariate analysis identified ABO incompatibility (P = 0.002) and low SMI (P = 0.045) as independent risk factors for bacteremia after LT. CONCLUSION Preoperative abnormal body composition was closely related to bacteremia after LDLT.
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Affiliation(s)
- Naoko Kamo
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshimi Kaido
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Yosuke Miyachi
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Sena Iwamura
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Siyuan Yao
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hisaya Shirai
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shintaro Yagi
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Ney M, Li S, Vandermeer B, Gramlich L, Ismond KP, Raman M, Tandon P. Systematic review with meta-analysis: Nutritional screening and assessment tools in cirrhosis. Liver Int 2020; 40:664-673. [PMID: 31571398 DOI: 10.1111/liv.14269] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 08/09/2019] [Accepted: 09/05/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Disease-related malnutrition is common in cirrhosis. Multiple studies have evaluated nutritional screening tools (NSTs, rapid bedside tests targeting who needs assessment) and nutritional assessment tools (NATs, used in diagnosing malnutrition) as predictors of clinical outcome in this population. We performed a systematic review and meta-analysis of this literature with the aim of summarising the varying definitions of malnutrition across studies, the available evidence for NSTs and the ability of NSTs and NATs to predict clinical outcomes in cirrhosis. METHODS The primary outcome measures were pre- and post-transplant mortality with a range of secondary outcomes. Inclusion: cirrhosis over age 16. Exclusion: >25% with hepatocellular carcinoma, primarily laboratory test-based NATs or lack of screening, assessment or outcome criteria. RESULTS Eight thousand eight hundred fifty patients were included across 47 studies. Only 3 studies assessed NSTs. Thirty-two definitions for malnutrition were utilised across studies. NATs predicted pre-transplant mortality in 69% of cases that were assessed with a risk ratio (RR) of 2.38 (95% CI 1.96-2.89). NATs were prognostic for post-transplant mortality only 28% of the times they were assessed, with a RR of 3.04 (95% CI 1.51-6.12). CONCLUSIONS The cirrhosis literature includes limited data on nutrition screening and multiple definitions for what constitutes malnutrition using NATs. Despite this discordance, it is clear that malnutrition is a valuable predictor of pre-transplant mortality almost regardless of how it is defined. We require clinical and research consensus around the definition of malnutrition and the accepted processes and cut-points for nutrition screening and assessment in cirrhosis.
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Affiliation(s)
- Michael Ney
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Suqing Li
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, AB, Canada
| | - Leah Gramlich
- Royal Alexandra Hospital, University of Alberta, Edmonton, AB, Canada
| | - Kathleen P Ismond
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Maitreyi Raman
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Puneeta Tandon
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
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Al-Judaibi B, Alqalami I, Sey M, Qumosani K, Howes N, Sinclair L, Chandok N, Eddin AH, Hernandez-Alejandro R, Marotta P, Teriaky A. Exercise Training for Liver Transplant Candidates. Transplant Proc 2019; 51:3330-3337. [DOI: 10.1016/j.transproceed.2019.08.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 08/30/2019] [Indexed: 02/06/2023]
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Nutrition Support of Children With Chronic Liver Diseases: A Joint Position Paper of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2019; 69:498-511. [PMID: 31436707 DOI: 10.1097/mpg.0000000000002443] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic liver disease places patients at increased risk of malnutrition that can be challenging to identify clinically and treat. Nutrition support is a key aspect of the management of these patients as it has an impact on their quality of life, morbidity, and mortality. There are significant gaps in the literature regarding the optimal nutrition support for patients with different types of liver diseases and the impact of these interventions on long-term outcomes. This Position Paper summarizes the available literature on the nutritional aspects of the care of patients with chronic liver diseases. Specifically, the challenges associated with the nutritional assessment of these subjects are discussed, and recently investigated approaches to determining the patients' nutritional status are reviewed. Furthermore, the pathophysiology of the malnutrition seen in the context of chronic liver disease is summarized and monitoring, as well as treatment, recommendations are provided. Lastly, suggestions for future research studies are described.
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Resting Energy Expenditure of Children With End-stage Chronic Liver Disease Before and After Liver Transplantation. J Pediatr Gastroenterol Nutr 2019; 69:102-107. [PMID: 30908388 DOI: 10.1097/mpg.0000000000002344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Our objective was to test the hypothesis that children with end-stage chronic liver disease (ESCLD) are hypermetabolic when compared to healthy children, and that this hypermetabolism persists for at least 6 months after liver transplant. METHODS Seventeen patients with end-stage chronic liver disease and 14 healthy controls had their resting energy expenditure measured (mREE) by indirect calorimetry. Weight, height, and body mass index were converted to standard deviation (SD) scores. Children older than 5 years had air displacement plethysmography and patients older than 5 years also had whole body dual-energy X-ray absorptiometry with characterization of fat mass (FM), fat-free mass (FFM), and bone-free fat free (lean) mass. RESULTS When compared to the prediction equation 44% of the patients and 50% of the healthy controls were hypermetabolic. The younger patients (0-5 years) had a lower mREE than the healthy controls but were significantly lighter and shorter than their healthy counterparts. mREE correlated strongly for all children with age, weight, height, and FFM. There was a strong negative correlation between age and mREE/kg in both patients (rs = -0.94, P < 0.01) and controls (rs = -0.91, P < 0.01). Almost 84% of the variance in mREE was explained by age (P < 0.001). There were no significant differences between resting energy expenditure (REE)/FFM between the 2 groups. mREE/kg before liver transplant correlated with mREE/kg after transplant (Pearson r = 0.83, P < 0.01). CONCLUSIONS REE mostly reflected the size of the child. The patients were not hypermetabolic when compared to the healthy children. The main determinant of REE/kg after transplant was REE/kg before transplant.
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Plauth M, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, Bischoff SC. ESPEN guideline on clinical nutrition in liver disease. Clin Nutr 2019; 38:485-521. [PMID: 30712783 DOI: 10.1016/j.clnu.2018.12.022] [Citation(s) in RCA: 322] [Impact Index Per Article: 64.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 02/06/2023]
Abstract
This update of evidence-based guidelines (GL) aims to translate current evidence and expert opinion into recommendations for multidisciplinary teams responsible for the optimal nutritional and metabolic management of adult patients with liver disease. The GL was commissioned and financially supported by ESPEN. Members of the guideline group were selected by ESPEN. We searched for meta-analyses, systematic reviews and single clinical trials based on clinical questions according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing the SIGN method. A total of 85 recommendations were made for the nutritional and metabolic management of patients with acute liver failure, severe alcoholic steatohepatitis, non-alcoholic fatty liver disease, liver cirrhosis, liver surgery and transplantation as well as nutrition associated liver injury distinct from fatty liver disease. The recommendations are preceded by statements covering current knowledge of the underlying pathophysiology and pathobiochemistry as well as pertinent methods for the assessment of nutritional status and body composition.
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Affiliation(s)
- Mathias Plauth
- Department of Internal Medicine, Municipal Hospital of Dessau, Dessau, Germany.
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Lindsay D Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Tatjana Schütz
- IFB Adiposity Diseases, Leipzig University Medical Centre, Leipzig, Germany
| | - Stephan C Bischoff
- Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany
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Shen F, Kim HJ, Lee NK, Chun HJ, Chang BS, Lee CK, Yeom JS. The influence of hand grip strength on surgical outcomes after surgery for degenerative lumbar spinal stenosis: a preliminary result. Spine J 2018; 18:2018-2024. [PMID: 29679727 DOI: 10.1016/j.spinee.2018.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 03/23/2018] [Accepted: 04/09/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although a number of prognostic factors have been demonstrated to be associated with surgical outcome of degenerative lumbar spinal stenosis (DLSS), no study has investigated the relation between hand grip strength (HGS) and treatment outcome of DLSS. PURPOSE The purpose of the present study was to examine the influence of HGS on surgical outcomes after surgery for patients with DLSS. STUDY DESIGN This is an observational study. PATIENT SAMPLE Patients who underwent spine surgery for DLSS were included in the study. OUTCOME MEASURES Oswestry Disability Index (ODI), EuroQOL (EQ-5D), and visual analog scale (VAS) scores for back or leg pain were assessed. MATERIALS AND METHODS A total of 172 consecutive patients who underwent spine surgery for DLSS were included in the present study. Patients were assigned to either high HGS group (≥26 kg for men and ≥18 kg for women, n=124) or low HGS group (<26 kg for men and <18 kg for women, n=48) based on their preoperative HGS performance. Oswestry Disability Index, EQ-5D, and VAS scores for back and leg pain were assessed and compared between two groups preoperatively, 3 and 6 months after surgery. The primary outcome measure was baseline-adjusted ODI scores 6 months after surgery. The secondary outcome measures, including the overall ODI score, EQ-5D score, VAS score for back and leg pain, were assessed at each time point during the 6-month follow-up period. RESULTS As primary outcome, baseline-adjusted ODI scores were significantly lower in the high HGS group than in the low HGS group 6 months after surgery. In the secondary outcome measurements, the ODI, EQ-5D, and VAS scores for back and leg pain improved significantly with time after surgery in both groups. The effects of HGS group on the overall changes in the ODI and EQ-5D scores during the 6-month period were significantly different between the two groups; however, they were not significantly different on VAS score for back and leg pain. The pattern of change in the ODI during the follow-up period was significantly different between the two groups. CONCLUSIONS Patients with preoperative high HGS display better surgical outcome in terms of disability and health status 6 months after spine surgery. Preoperative HGS can act as a predictor of surgical outcome in patients with DLSS.
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Affiliation(s)
- Feng Shen
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Sungnam 463-707, Republic of Korea
| | - Ho-Joong Kim
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Sungnam 463-707, Republic of Korea.
| | - Na-Kyoung Lee
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Sungnam 463-707, Republic of Korea
| | - Heoung-Jae Chun
- Department of Mechanical Engineering, Yonsei University, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Bong-Soon Chang
- Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea
| | - Choon-Ki Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea
| | - Jin S Yeom
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Sungnam 463-707, Republic of Korea
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Laici C, Gamberini L, Bardi T, Siniscalchi A, Reggiani MLB, Faenza S. Early infections in the intensive care unit after liver transplantation-etiology and risk factors: A single-center experience. Transpl Infect Dis 2018; 20:e12834. [PMID: 29359867 DOI: 10.1111/tid.12834] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/26/2017] [Accepted: 10/29/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Infectious complications represent one of the main causes of perioperative morbidity and mortality of liver transplant recipients. The primary objective of this retrospective observational study was to evaluate incidence and etiology of early (within 1 month from surgery and occurring in the intensive care unit [ICU]) postoperative infections as well as donor- and recipient-related risk factors. METHODS The data of 280 patients undergoing 299 consecutive liver transplant procedures from January 2012 to December 2015 were extracted from the Italian ICU registry database and hospital registries. Perioperative risk factors, etiology of infections, and antibiotic susceptibility of isolated microorganisms were taken into consideration. RESULTS Global incidence of postoperative infections was 21%. Pneumonia was the most frequent infection and, globally, gram-negative bacteria were the most common agents. Septic shock was present in 22% of infection cases and hospital mortality was higher in patients with postoperative infection. Preoperative chronic obstructive pulmonary disease, malnutrition, preoperative ascites, encephalopathy, and early re-transplantation were significantly associated to post orthotopic LT infections. CONCLUSION Infections represent a major cause of early postoperative morbidity and mortality. The impact of single risk factors and the results of their preoperative management should be further investigated in order to reduce the incidence and evolution of postoperative infections.
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Affiliation(s)
- Cristiana Laici
- Division of Anesthesiology, Hospital S. Orsola Malpighi, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Lorenzo Gamberini
- Division of Anesthesiology, Hospital S. Orsola Malpighi, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Tommaso Bardi
- Division of Anesthesiology, Hospital S. Orsola Malpighi, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Antonio Siniscalchi
- Division of Anesthesiology, Hospital S. Orsola Malpighi, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Maria Letizia Bacchi Reggiani
- Department of Statistics, Diagnostic and Experimental Medicine, Hospital S. Orsola Malpighi, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Stefano Faenza
- Division of Anesthesiology, Hospital S. Orsola Malpighi, Alma Mater Studiorum University of Bologna, Bologna, Italy
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Resolving Malnutrition With Parenteral Nutrition Before Liver Transplant in Biliary Atresia. J Pediatr Gastroenterol Nutr 2018; 66:212-217. [PMID: 29356765 DOI: 10.1097/mpg.0000000000001798] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Malnutrition is a common complication of end-stage liver disease (ESLD) associated with poor liver transplant outcomes. Nasogastric feeds are used for nutritional supplementation, but some patients remain malnourished. Parenteral nutrition (PN) can be effective, but has potential complications. The primary objective was to evaluate the effect of PN on anthropometric measures in children with ESLD awaiting liver transplant. Secondary objectives were evaluation of PN-associated complications, liver function tests, pediatric end-stage liver disease scores, waitlist time, and post-transplant length of stay (total and time in the intensive care unit). METHODS A single-center, retrospective chart review analyzing pediatric patients with ESLD receiving PN who were transplanted during a 6-year period. Data were trended and described over time, as were the relationships between anthropometric data and time receiving PN. RESULTS A total of 44 patients with ESLD were transplanted between January 2010 and December 2015. Eighteen (41%) received PN before transplant; all had biliary atresia with median age at transplant of 10 months (range, 5-18 months). Mid-upper arm circumference and triceps skinfold thickness showed resolution of malnutrition in 7 patients (39%) with normalization of 1 measure in another 4 patients (22%). Of the remaining, 6 had improved z scores and 1 had worsening malnutrition. No deaths occurred in patients receiving PN. Central line infection rates were 3.8/1000 catheter days with 8 total infections in 6 patients over a total of 2117 catheter days. CONCLUSIONS Children with ESLD and malnutrition who have failed enteral feeding may benefit from PN to improve and/or resolve malnutrition before liver transplant.
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Hammad A, Kaido T, Aliyev V, Mandato C, Uemoto S. Nutritional Therapy in Liver Transplantation. Nutrients 2017; 9:E1126. [PMID: 29035319 PMCID: PMC5691742 DOI: 10.3390/nu9101126] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/10/2017] [Accepted: 10/12/2017] [Indexed: 12/11/2022] Open
Abstract
Protein-energy malnourishment is commonly encountered in patients with end-stage liver disease who undergo liver transplantation. Malnutrition may further increase morbidity, mortality and costs in the post-transplantation setting. The importance of carefully assessing the nutritional status during the work-up of patients who are candidates for liver replacement is widely recognized. The metabolic abnormalities induced by liver failure render the conventional assessment of nutritional status to be challenging. Preoperative loss of skeletal muscle mass, namely, sarcopenia, has a significant detrimental impact on post-transplant outcomes. It is essential to provide sufficient nutritional support during all phases of liver transplantation. Oral nutrition is preferred, but tube enteral nutrition may be required to provide the needed energy intake. Herein, the latest currently employed perioperative nutritional interventions in liver transplant recipients are thoroughly illustrated including synbiotics, micronutrients, branched-chain amino acid supplementation, immunonutrition formulas, fluid and electrolyte balance, the offering of nocturnal meals, dietary counselling, exercise and rehabilitation.
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Affiliation(s)
- Ahmed Hammad
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan.
- Department of General Surgery, Mansoura University, Mansoura 35516, Egypt.
| | - Toshimi Kaido
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan.
| | - Vusal Aliyev
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan.
| | - Claudia Mandato
- L'AORN Children's Hospital Santobono and Pausilipon, Napoli 80122, Italy.
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan.
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Effect of Preoperative Growth Status on Clinical Outcomes After Living-Donor Liver Transplantation in Infants. Transplant Proc 2017; 49:1848-1854. [DOI: 10.1016/j.transproceed.2017.06.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/16/2017] [Indexed: 12/27/2022]
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Marseglia A, Ginammi M, Bosisio M, Stroppa P, Colledan M, D'Antiga L. Determinants of large drain losses early after pediatric liver transplantation. Pediatr Transplant 2017; 21. [PMID: 28417522 DOI: 10.1111/petr.12932] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2017] [Indexed: 12/21/2022]
Abstract
The goal of this study was to evaluate postoperative ascites to correlate it with graft dysfunction and other complications. We therefore reviewed the files of patients transplanted between 2009 and 2014 to correlate drain losses with indication, patient and organ size, PELD, graft type, GRWR, NRBW, NGWD, cold ischemia time, histologically proven graft dysfunction, and surgical complications. Of 120 LTs in 104 patients, 48 (40%) were complicated by graft dysfunction, 43 (36%) by surgical complications, and 25 (21%) by cellular rejection. Large drain losses correlated with younger age (P=.05), graft dysfunction (P<.01), surgical complications (P<.01), chylous ascites (P=.05); there was no association with PELD, GRWR, NRBW, or NGWD. Graft dysfunction was predicted by >20 mL/kg/d of ascites at age 0-2 years (AUROC 0.671), and >10 mL/kg/d above 2 years (AUROC 0.710). The measurement of drain losses after pediatric LT could be used as a non-invasive marker of graft dysfunction. Younger recipients tend to develop larger amounts of ascites, and its persistence is associated with early complications.
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Affiliation(s)
- Antonio Marseglia
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Marco Ginammi
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Michela Bosisio
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Paola Stroppa
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Michele Colledan
- Department of Transplant Surgery, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Lorenzo D'Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
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NUNES G, SANTOS CA, BAROSA R, FONSECA C, BARATA AT, FONSECA J. OUTCOME AND NUTRITIONAL ASSESSMENT OF CHRONIC LIVER DISEASE PATIENTS USING ANTHROPOMETRY AND SUBJECTIVE GLOBAL ASSESSMENT. ARQUIVOS DE GASTROENTEROLOGIA 2017; 54:225-231. [DOI: 10.1590/s0004-2803.201700000-28] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 03/07/2017] [Indexed: 12/11/2022]
Abstract
ABSTRACT BACKGROUND: Protein-calorie malnutrition is common in chronic liver disease (CLD) but adequate clinical tools for nutritional assessment are not defined. OBJECTIVE: In CLD patients, it was aimed: 1. Characterize protein-calorie malnutrition; 2. Compare several clinical, anthropometric and functional tools; 3. Study the association malnutrition/CLD severity and malnutrition/outcome. METHODS: Observational, prospective study. Consecutive CLD ambulatory/hospitalised patients were recruited from 01-03-2012 to 31-08-2012, studied according with age, gender, etiology, alcohol consumption and CLD severity defined by Child-Turcotte-Pugh. Nutritional assessment used subjective global assessment, anthropometry, namely body-mass index (BMI), triceps skinfold, mid upper arm circumference, mid arm muscular circumference and handgrip strength. Patients were followed during two years and survival data was recorded. RESULTS: A total of 130 CLD patients (80 men), aged 22-89 years (mean 60 years) were included. Most suffered from alcoholic cirrhosis (45%). Hospitalised patients presented more severe disease ( P <0.001) and worst nutritional status defined by BMI ( P =0.002), mid upper arm circumference ( P <0.001), mid arm muscular circumference ( P <0.001), triceps skinfold ( P =0.07) and subjective global assessment ( P <0.001). A third presented deficient/low handgrip strength. Alcohol consumption ( P =0.03) and malnutrition detected by BMI ( P =0.03), mid upper arm circumference ( P =0.001), triceps skinfold ( P =0.06), mid arm muscular circumference ( P =0.02) and subjective global assessment ( P <0.001) were associated with CLD severity. From 25 patients deceased during follow-up, 17 patients were severely malnourished according with triceps skinfold. Malnutrition defined by triceps skinfold predicted mortality ( P <0.001). CONCLUSION: Protein-calorie malnutrition is common in CLD patients and alcohol plays an important role. Triceps skinfold is the most efficient anthropometric parameter and is associated with mortality. Nutritional assessment should be considered mandatory in the routine care of CLD patients.
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Affiliation(s)
| | | | | | | | | | - Jorge FONSECA
- GENE - Artificial Feeding Team, Portugal; Centro de Investigação Interdisciplinar Egas Moniz, Portugal
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Nutritional status using subjective global assessment independently predicts outcome of patients waiting for living donor liver transplant. Indian J Gastroenterol 2017; 36:275-281. [PMID: 28856568 DOI: 10.1007/s12664-017-0779-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/22/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Malnutrition is an important risk factor for adverse outcomes in patients awaiting liver transplant. Living donor liver transplant, being an elective procedure, allows nutritional rehabilitation and optimization of these patients before transplant. AIM This paper aimed to evaluate the outcome of end-stage liver disease (ESLD) patients with various degrees of malnutrition waiting for living donor liver transplant. METHODS Nutritional status was assessed using subjective global assessment (SGA) in patients who were evaluated for a liver transplant at our center from January 2015 to September 2015. All the data were collected prospectively. Predictive factors for mortality were analyzed using logistic regression and survival was obtained using Kaplan-Meier curves. RESULTS One hundred and seventeen patients were grouped based on their nutrition status into normal, mild-moderate, and severe malnutrition. The groups were comparable in terms of age, sex, etiology of liver disease except alcoholic liver disease. Graft recipient weight ratio was comparable among groups. There was no significant difference in hospital stay. However, severe malnourished patients had higher incidence of sepsis (p=0.005) and death due to sepsis (p=0.01). Nutritional status was the only independent predictor of mortality on multivariate analysis. CONCLUSION Nutritional status measured with SGA independently predicts short-term outcome of ESLD patients waiting and after living donor liver transplant.
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Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale R, Waitzberg DL, Bischoff SC, Singer P. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017; 36:623-650. [DOI: 10.1016/j.clnu.2017.02.013] [Citation(s) in RCA: 941] [Impact Index Per Article: 134.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 02/07/2023]
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Abstract
Malnutrition is associated with alcoholic liver disease (ALD) and related complications such as hepatic encephalopathy and increased rate of infections. Avoidance of prolonged fasting and overly restrictive diets is important to avoid poor nutrition. Adequate intake of calories, protein, and micronutrients via frequent small meals and evening supplements and/or enteral and parenteral nutrition when indicated has been associated with reduced mortality and morbidity in patients with ALD. Modification of protein/fat sources and composition in addition to probiotic supplementation are promising interventions for decreased progression of ALD and its complications.
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Abstract
The rates of morbidity and mortality after liver transplantation are related to the degree of malnutrition. Because malnutrition is prevalent among liver transplant recipients, nutrition care practitioners must be aggressive in providing nutrition support to these patients in the perioperative period. Postoperative tube feeding (TF) has been studied for its role in improving short-term posttransplant outcomes. This paper evaluates published research that studied postoperative TF in liver transplant recipients; the methodology and outcomes are reviewed and drawbacks of these studies are considered. Case studies of liver transplant patients who received postoperative TF illustrate the variability of patient profiles and posttransplant complications that influence the provision and duration of posttransplant TF.
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Affiliation(s)
- Jeanette M Hasse
- Baylor Institute of Transplantation, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246, USA.
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Fernandez TMA, Gardiner PJ. Critical Care of the Liver Transplant Recipient. CURRENT ANESTHESIOLOGY REPORTS 2015; 5:419-428. [PMID: 32288651 PMCID: PMC7101679 DOI: 10.1007/s40140-015-0133-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patient survival following orthotopic liver transplantation has greatly increased following improvements in surgical technique, anesthetic care, and immunosuppression. The critical care of the liver transplant recipient has paralleled these improvements, largely thanks to input from multidisciplinary teams and institution-specific protocols guiding management and care. This article provides an overview of the approach to critical care of the postoperative adult liver transplant recipient outlining common issues faced by the intensivist. Approaches to extubation and hemodynamic assessment are described. The provision of appropriate immunosuppression, infection prophylaxis, and nutrition is addressed. To aid prompt diagnosis and treatment, intensivists must be aware of postoperative complications of bleeding, primary nonfunction, delayed graft function, vascular thromboses, biliary complications, rejection, and organ dysfunction.
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Affiliation(s)
- Thomas M. A. Fernandez
- Department of Anesthesia and Perioperative Care, Auckland City Hospital, 2 Park Road, Grafton, Auckland, 1023 New Zealand
| | - Paul J. Gardiner
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
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Zhang QK, Wang ML. The management of perioperative nutrition in patients with end stage liver disease undergoing liver transplantation. Hepatobiliary Surg Nutr 2015; 4:336-44. [PMID: 26605281 DOI: 10.3978/j.issn.2304-3881.2014.09.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Malnutrition is found in almost 100% of patients with end stage liver disease (ESLD) awaiting transplantation and malnutrition before transplantation leads to higher rates of post-transplant complications and worse graft survival outcomes. Reasons for protein energy malnutrition include several metabolic alterations such as inadequate intake, malabsorption, and overloaded expenditure. And also, stress from surgery, gastrointestinal reperfusion injury, immunosuppressive therapy and corticosteriods use lead to delayed bowl function recovery and disorder of nutrients absorption. In the pretransplant phase, nutritional goals include optimization of nutritional status and treatment of nutrition-related symptoms induced by hepatic decompensation. During the acute post-transplant phase, adequate nutrition is required to help support metabolic demands, replenish lost stores, prevent infection, arrive at a new immunologic balance, and promote overall recovery. In a word, it is extremely important to identify and correct nutritional deficiencies in this population and provide an adequate nutritional support during all phases of liver transplantation (LT). This study review focuses on prevalence, nutrition support, evaluation, and management of perioperative nutrition disorder in patients with ESLD undergoing LT.
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Affiliation(s)
- Qi-Kun Zhang
- Department of Hepatobiliary Surgery and Liver Transplantation Center, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Meng-Long Wang
- Department of Hepatobiliary Surgery and Liver Transplantation Center, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
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40
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Kim JM, Joh JW, Kim HJ, Kim SH, Rha M, Sinn DH, Choi GS, Kwon CHD, Cho YY, Suh JM, Lee SK. Early Enteral Feeding After Living Donor Liver Transplantation Prevents Infectious Complications: A Prospective Pilot Study. Medicine (Baltimore) 2015; 94:e1771. [PMID: 26554774 PMCID: PMC4915875 DOI: 10.1097/md.0000000000001771] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Infectious complications, including bacteria, virus, and fungus, often occur after liver transplantation and are the most frequent causes of in-hospital mortality. The current study prospectively analyze the effect of early enteral feeding in patients after living donor liver transplantation (LDLT)Between January 2013 and August 2013, 36 patients underwent LDLT. These patients were randomly assigned to receive enteral formula via nasointestinal feeding tubes [enteral feeding (EN) group, n = 17] or maintenance on intravenous fluid until oral diets were initiated (control group, n = 19). All patients completed the study.The pretransplant and perioperative characteristics of patients did not differ between the 2 groups. The incidence of bacterial infection was significantly lower in the EN group (29.4%) than in the control group (63.2%) (P = 0.043). In addition, the incidence of bile duct complications in the EN group was lower than in the control group (5.9% versus 31.6%, P = 0.041). Multivariate analysis showed that early enteral feeding was closely associated with bacterial infections (odds ratio, 0.178; P = 0.041). There was no statistically significant difference in nutritional status between the 2 groups. There were no cases of in-hospital mortality.Early enteral feeding after LDLT prevents posttransplant bacterial infection, suggesting the possibility of a reduction of in-hospital mortality as a result of decreased infectious complications.
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Affiliation(s)
- Jong Man Kim
- From the Department of Surgery, Sungkyunkwan University School of Medicine (JMK, J-WJ, HJK, G-SC, CHDK, J-MS, S-KL); Department of Dietetics (S-HK, MR, YYC); and Division of Gastroenteology, Department of Medicine, Sungkyunkwan University School of Medicine, Seoul, South Korea (DHS)
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Kallwitz ER. Sarcopenia and liver transplant: The relevance of too little muscle mass. World J Gastroenterol 2015; 21:10982-10993. [PMID: 26494955 PMCID: PMC4607898 DOI: 10.3748/wjg.v21.i39.10982] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/09/2015] [Accepted: 09/14/2015] [Indexed: 02/07/2023] Open
Abstract
Loss of muscle mass and function is a common occurrence in both patients with decompensated cirrhosis and those undergoing liver transplantation. Sarcopenia is associated with morbidity and mortality before and after liver transplantation. The ability of skeletal muscle mass to recover after transplant is questionable, and long term adverse events associated with persistent sarcopenia have not been well studied. Limited data is available examining mechanisms by which decreased muscle mass might develop. It is not clear which interventions might reduce the prevalence of sarcopenia and associated health burdens. However, measures to either decrease portal hypertension or improve nutrition appear to have benefit. Research on sarcopenia in the liver transplant setting is hampered by differing methodology to quantify muscle mass and varied thresholds determining the presence of sarcopenia. One area highlighted in this review is the heterogeneity used when defining sarcopenia. The health consequences, clinical course and potential pathophysiologic mechanisms of sarcopenia in the setting of cirrhosis and liver transplantation are further discussed.
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Bambha KM, Dodge JL, Gralla J, Sprague D, Biggins SW. Low, rather than high, body mass index confers increased risk for post-liver transplant death and graft loss: Risk modulated by model for end-stage liver disease. Liver Transpl 2015; 21:1286-94. [PMID: 26097202 DOI: 10.1002/lt.24188] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 05/13/2015] [Accepted: 05/31/2015] [Indexed: 12/12/2022]
Abstract
With increasing attention being paid to optimizing patient outcomes, it has been proposed that liver transplantation (LT) for individuals with elevated body mass index (BMI) values and high Model for End-Stage Liver Disease (MELD) scores may adversely affect post-LT outcomes. We investigated the impact of BMI on post-LT outcomes in the context of MELD at LT. Using United Network for Organ Sharing data, we identified all adult (≥ 18 years) primary LT recipients from March 1, 2002 to September 30, 2011. BMI categories included the following: underweight, normal, overweight, class I obese, class II obese, and class III obese (<18.5; 18.5-24.9; 25-29.9; 30-34.9; 35-39.9; ≥ 40 kg/m(2), respectively). One-year post-LT death and graft loss were modeled using Cox regression, including interactions between BMI and MELD. A total of 45,551 adult recipients were identified: 68% male; median (interquartile range [IQR]) age 55 years (IQR, 49-60 years); MELD, 19 (IQR, 13-26); and donor risk index, 1.39 (IQR, 1.12-1.69). Representations in the BMI categories were underweight (n = 863, 2%), normal (n = 13,262, 29%), overweight (n = 16,329, 36%), class I obese (n = 9639, 21%), class II obese (n = 4062, 9%), and class III obese (n = 1396, 3%). In adjusted analyses, elevated BMI was not associated with increased risk for death or graft loss. Among the underweight, there were significant interactions between BMI and MELD with respect to death (P = 0.02) and graft loss (P = 0.01), with significantly increased risks for death (hazard ratio [HR], 1.70; 95% confidence interval [CI], 1.38-2.09; P = 0.006) and graft loss (HR, 1.45; 95% CI, 1.21-1.74; P = 0.02) among those with low MELD (≤ 26), compared to normal BMI recipients with low MELD. In conclusion, overweight and obese LT recipients do not have increased risk of death or graft loss regardless of MELD. Underweight patients are at increased risk for poor outcomes post-LT, specifically underweight recipients with low MELD have increased risk for death and graft loss. Mechanisms underlying this phenomenon warrant further investigation.
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Affiliation(s)
- Kiran M Bambha
- Division of Gastroenterology and Hepatology, University of Colorado Denver, Aurora, CO
| | - Jennifer L Dodge
- Division of Transplant Surgery, University of California, San Francisco, CA
| | - Jane Gralla
- Department of Pediatrics, University of Colorado Denver, Aurora, CO
| | - David Sprague
- Division of Gastroenterology and Hepatology, University of Colorado Denver, Aurora, CO
| | - Scott W Biggins
- Division of Gastroenterology and Hepatology, University of Colorado Denver, Aurora, CO
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43
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Otto M, Kautt S, Kremer M, Kienle P, Post S, Hasenberg T. Handgrip strength as a predictor for post bariatric body composition. Obes Surg 2015; 24:2082-8. [PMID: 24902652 DOI: 10.1007/s11695-014-1299-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND After bariatric surgery, the postoperative quality of weight loss is variable. The aim of weight loss treatment is to reduce fat mass while keeping fat free mass, in particular body cell mass (BCM), constant. Detection of low BCM is an important aspect of surgical follow up. Handgrip dynamometry is a rapid and inexpensive test to measure static muscle strength, which is an independent outcome indicator of various medical conditions. The objective of this study is to examine the change in handgrip strength after bariatric surgery and its predictive value for postoperative body composition. Furthermore, this study was carried out at the University Hospital, Germany. METHODS Twenty-five patients who underwent a bariatric procedure (laparoskopic Roux-Y gastric bypass n=16 or sleeve resection n=9) were included in this study. Bioelectrical impedance analysis and hand-grip strength were measured preoperatively and repeated every 6 weeks for 4 months. An analysis of variance was performed to observe the changes in these individual parameters. RESULTS Postoperatively, all patients showed a significant decrease in the body mass index and body fat. The extracellular mass, BCM, and the lean mass of the patients remained constant. Handgrip strength showed no significant changes during the postoperative course. Nevertheless, the preoperative hand-grip strength showed a strong positive correlation with the postoperative body composition. CONCLUSIONS This study showed no changes in the static muscle force after bariatric surgery. The preoperative handgrip strength was strongly correlated with postoperative body composition and may be used to identify patients who need more attention before surgery and in the early postoperative phase.
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Affiliation(s)
- Mirko Otto
- Department of Surgery, UMM, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany,
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Dela Cruz AC, Vilchez V, Kim S, Barnes B, Ravinuthala A, Zanni A, Galuppo R, Sourianarayanane A, Patel T, Maynard E, Shah MB, Daily MF, Uhl T, Esser K, Gedaly R. A prospective analysis of factors associated with decreased physical activity in patients with cirrhosis undergoing transplant evaluation. Clin Transplant 2015; 29:958-64. [PMID: 26263921 DOI: 10.1111/ctr.12602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Physical activity (PA) has been associated with improved recovery time after transplantation. Handgrip strength has been related to post-transplant outcomes. AIM To evaluate predictors of PA and grip strength in patients with cirrhosis undergoing liver transplant evaluation. METHODS Single-center, prospective analysis. RESULTS One hundred patients were evaluated (54% male, mean age 53 ± 9). Common etiologies of liver disease were non-alcoholic steatohepatitis (27%), hepatitis C (22%) and alcoholic liver disease (21%). Mean model of end-stage liver disease (MELD) score was 13.5. Forty-one percent had a history of smoking. Ninety-three patients completed the International Physical Activity Questionnaire (IPAQ). The median total PA score was 33 metabolic equivalent (MET)-min/wk. The mean total grip strength was 62.1 ± 22 lb. Total grip strength was found to be an independent predictor of low-moderate PA (OR 4.7, 95% CI 1.4-16.2, p = 0.038), and smoking was the only significant factor associated with reduced grip strength (OR 3.4, 95% CI 1.4-8, p = 0.005). CONCLUSIONS Patients with end-stage liver disease undergoing liver transplant evaluation have reduced total PA by IPAQ. Total grip strength was found to be a significant predictor of low-moderate PA in patients with cirrhosis. Smoking is a risk factor for reduced grip strength, an important indicator of muscle wasting in cirrhotics.
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Affiliation(s)
- Anna Christina Dela Cruz
- Department of Internal Medicine, Gastroenterology and Hepatology, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Valery Vilchez
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Sooyeon Kim
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Benjamin Barnes
- Center for Muscle Biology, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Abhishek Ravinuthala
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Anthony Zanni
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Roberto Galuppo
- Department of Radiology, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Achuthan Sourianarayanane
- Department of Internal Medicine, Gastroenterology and Hepatology, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Trushar Patel
- Department of Internal Medicine, Gastroenterology and Hepatology, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Erin Maynard
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Malay B Shah
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Michael F Daily
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Timothy Uhl
- Center for Muscle Biology, University of Kentucky, College of Medicine, Lexington, KY, USA.,Department of Rehabilitation Sciences, University of Kentucky, College of Health Sciences, Lexington, KY, USA
| | - Karyn Esser
- Center for Muscle Biology, University of Kentucky, College of Medicine, Lexington, KY, USA
| | - Roberto Gedaly
- Department of Surgery - Transplant Division, University of Kentucky, College of Medicine, Lexington, KY, USA
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45
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Ross LJ, Capra S, Baguley B, Sinclair K, Munro K, Lewindon P, Lavin M. Nutritional status of patients with ataxia-telangiectasia: A case for early and ongoing nutrition support and intervention. J Paediatr Child Health 2015; 51:802-7. [PMID: 25656498 DOI: 10.1111/jpc.12828] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2014] [Indexed: 11/29/2022]
Abstract
AIM Ataxia-telangiectasia (A-T) is a rare genomic syndrome resulting in severe disability. Chronic childhood disorders can profoundly influence growth and development. Nutrition-related issues in A-T are not well described, and there are no nutritional guidelines. This study investigated the nutrition-related characteristics and behaviours of Australian A-T patients attending a national clinic. METHODS A cross-sectional analysis of 13 A-T patients (nine females; aged: 4-23 years): nutritional status was assessed by anthropometric and body cell mass (BCM) calculations. Parents reported their child's diet history and physical and behavioural factors that affect nutrition including fatigue and need for assistance. RESULTS Ten (77%) had short stature (height for age z scores <-1), and seven (54%) were underweight for height (weight/height z scores <-1). Significant malnutrition (BCM z scores <-2) was detected in nine (69%) including the one adult who was severely malnourished. Malnutrition increased significantly with age (BCM for height z scores and age, r = -0.937, P < 0.001). Eight (62%) patients ate poorly compared with estimated energy requirement for weight. Poor diet quality was characterised by high fat and sugar choices. Parents reported significant nutritional barriers as chronic tiredness and the need for care giver assistance with meals. CONCLUSIONS This study confirms profound malnutrition in Australian A-T patients. Poor intakes and diet quality suggest the need for early nutrition intervention. Ongoing support for families and early discussions on tube feeding are required to address changing needs in childhood and likely nutritional decline into adulthood. A prospective study is required to assess feasibility and effectiveness of nutrition interventions in young people with A-T.
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Affiliation(s)
- Lynda J Ross
- Department of Nutrition and Dietetics, The Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Sandra Capra
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Brenton Baguley
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Kate Sinclair
- Department of Neurology, The Royal Children's Hospital Brisbane, Brisbane, Queensland, Australia
| | - Kate Munro
- Department of Neurology, The Royal Children's Hospital Brisbane, Brisbane, Queensland, Australia
| | - Peter Lewindon
- School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Queensland, Australia.,Department of Neurology, The Royal Children's Hospital Brisbane, Brisbane, Queensland, Australia.,Department of Gastroenterology, The Royal Children's Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Institute of Medical Research (QIMR), Brisbane, Queensland, Australia
| | - Martin Lavin
- The University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
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46
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Port GZ, Oliveira K, Soldera J, Tovo CV. Biochemical nutritional profile of liver cirrhosis patients with hepatocellular carcinoma. ARQUIVOS DE GASTROENTEROLOGIA 2014; 51:10-5. [PMID: 24760057 DOI: 10.1590/s0004-28032014000100003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 10/05/2013] [Indexed: 12/23/2022]
Abstract
CONTEXT Liver cirrhosis patients with hepatocellular carcinoma present nutritional alterations and metabolic disorders that negatively impact the prognosis. OBJECTIVE The objective is to identify alterations in the metabolism of macro and micronutrients among liver cirrhosis patients with and without hepatocellular carcinoma and their relation to the Child-Turcote-Pugh score and Barcelona Clinic Liver Cancer staging. METHODS Analytical transversal study, with 31 hepatocellular carcinoma patients and 48 liver cirrhosis patients. Laboratorial exams were carried out. The existence of an association between the biochemical parameters and the disease severity as well as the presence of hepatocellular carcinoma was assessed. RESULTS The metabolic-nutritional profile of liver cirrhosis patients caused by the hepatitis C virus and hepatocellular carcinoma showed alterations, specifically the lipid (total cholesterol, HDL and triglycerides), protein (albumin, creatinine and uric acid), iron (transferrin, iron and ferritin saturation), hematocrit and hemoglobin, zinc and B12 vitamin profiles. There is a relation between nutritional biochemical markers and the Child-Turcote-Pugh, as well as Barcelona Clinic Liver Cancer staging. CONCLUSIONS Considering the existence of alterations in the metabolism of nutrients in liver cirrhosis patients with and without hepatocellular carcinoma, and also that conventional nutritional assessment methods present limitations for this population, the biochemical laboratorial exams are valid to complement the diagnosis of the nutritional state in a quick and practical manner.
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Affiliation(s)
- Gabriela Zanatta Port
- Pós Graduação do Curso de Hepatologia, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
| | - Kalinca Oliveira
- Pós Graduação do Curso de Hepatologia, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
| | - Jonathan Soldera
- Pós Graduação do Curso de Hepatologia, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
| | - Cristiane Valle Tovo
- Pós Graduação do Curso de Hepatologia, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
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47
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Guerra RS, Amaral TF, Sousa AS, Pichel F, Restivo MT, Ferreira S, Fonseca I. Handgrip strength measurement as a predictor of hospitalization costs. Eur J Clin Nutr 2014; 69:187-92. [PMID: 25369830 DOI: 10.1038/ejcn.2014.242] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 09/16/2014] [Accepted: 09/27/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND Undernutrition status at hospital admission is related to increased hospital costs. Handgrip strength (HGS) is an indicator of undernutrition, but the ability of HGS to predict hospitalization costs has yet to be studied. OBJECTIVE To explore whether HGS measurement at hospital admission can predict patient's hospitalization costs. SUBJECTS/METHODS A prospective study was conducted in a university hospital. Inpatient's (n=637) HGS and undernutrition status by Patient-Generated Subjective Global Assessment were ascertained. Multivariable linear regression analysis, computing HGS quartiles by sex (reference: fourth quartile, highest), was conducted in order to identify the independent predictors of hospitalization costs. Costs were evaluated through percentage deviation from the mean cost, after adjustment for patients' characteristics, disease severity and undernutrition status. RESULTS Being in the first or second HGS quartiles at hospital admission increased patient's hospitalization costs, respectively, by 17.5% (95% confidence interval: 2.7-32.3) and 21.4% (7.5-35.3), which translated into an increase from €375 (58-692) to €458 (161-756). After the additional adjustment for undernutrition status, being in the first or second HGS quartiles had, respectively, an economic impact of 16.6% (1.9-31.2) and 20.0% (6.2-33.8), corresponding to an increase in hospitalization expenditure from €356 (41-668) to €428 (133-724). CONCLUSIONS Low HGS at hospital admission is associated with increased hospitalization costs of between 16.6 and 20.0% after controlling for possible confounders, including undernutrition status. HGS is an inexpensive, noninvasive and easy-to-use method that has clinical potential to predict hospitalization costs.
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Affiliation(s)
- R S Guerra
- 1] Departamento de Bioquímica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal [2] UISPA-IDMEC, Faculdade de Engenharia da Universidade do Porto, Porto, Portugal [3] Unidade de Nutrição, Centro Hospitalar do Porto, Porto, Portugal
| | - T F Amaral
- 1] UISPA-IDMEC, Faculdade de Engenharia da Universidade do Porto, Porto, Portugal [2] Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto, Porto, Portugal
| | - A S Sousa
- 1] Unidade de Nutrição, Centro Hospitalar do Porto, Porto, Portugal [2] Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto, Porto, Portugal
| | - F Pichel
- Unidade de Nutrição, Centro Hospitalar do Porto, Porto, Portugal
| | - M T Restivo
- UISPA-IDMEC, Faculdade de Engenharia da Universidade do Porto, Porto, Portugal
| | - S Ferreira
- Serviço de Informação de Gestão, Centro Hospitalar do Porto, Porto, Portugal
| | - I Fonseca
- Unidade de Nutrição, Centro Hospitalar do Porto, Porto, Portugal
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Abstract
Liver transplantation (LT) is a major surgery performed on patients with end stage liver disease. Nutrition is an integral part of patient care, and protein-energy malnutrition is almost universally present in patients suffering from liver disease undergoing LT. Nutrition assessment of preliver transplant phase helps to make a good nutrition care plan for the patients. Nutrition status has been associated with various factors which are related to the success of liver transplant such as morbidity, mortality, and length of hospital stay. To assess the nutritional status of preliver transplant patients, combinations of nutrition assessment methods should be used like subjective global assessment, Anthropometry mid arm-muscle circumference, Bioelectrical impedance analysis (BIA) and handgrip strength.
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Affiliation(s)
- Neha Bakshi
- Lady Irwin College, Department of Foods and Nutrition, University of Delhi, New Delhi, India
| | - Kalyani Singh
- Lady Irwin College, Department of Foods and Nutrition, University of Delhi, New Delhi, India
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Sun Y, Yang Z, Tan H. Perioperative nutritional support and fluid therapy in patients with liver diseases. Hepatobiliary Surg Nutr 2014; 3:140-8. [PMID: 25019075 DOI: 10.3978/j.issn.2304-3881.2014.04.05] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 03/31/2014] [Indexed: 12/13/2022]
Abstract
The prevalence of liver dysfunction and malnutrition is common among patients with obstructive jaundice or cirrhosis, the poor nutrition status in patients with indications for hepatic resection increases the risk of postoperative complications and/or mortality. Hepatic surgery significantly affects body's metabolism and environment. Therefore, it is very important for patients with liver diseases undergoing hepatic surgery to receive essential nutritional support and fluid therapy during perioperative period. There are several principles in nutritional support and fluid therapy that surgeons need to pay attention to, for example, time, nutritional approach, fluid volume, choice of fat emulsions and amino acids. Some issues, such as albumin and plasma application, choice of crystalloid and colloid, liver protective therapy, also need further attention.
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Affiliation(s)
- Yongliang Sun
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Zhiying Yang
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Haidong Tan
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing 100029, China
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50
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Prognostic value of muscle atrophy in cirrhosis using psoas muscle thickness on computed tomography. J Hepatol 2014; 60:1151-7. [PMID: 24607622 DOI: 10.1016/j.jhep.2014.02.026] [Citation(s) in RCA: 261] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 02/03/2014] [Accepted: 02/22/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Waiting-list mortality in patients with cirrhosis and a relatively low MELD score is a matter of concern. The aim of this study was to determine whether a marker of muscle waste could improve prognostication. METHODS A pre-MELD cohort (waiting time-based allocation; n=186) and a MELD-era cohort (n=376) were examined. At evaluation, transversal psoas muscle thickness (TPMT) was measured on a computed tomography (CT) image at the level of the umbilicus. In the pre-MELD cohort, TPMT/height (mm/m) and the MELD score were entered in univariate and multivariate models to predict mortality after registration. Applicability of pre-MELD findings was tested in the MELD-era. RESULTS In the pre-MELD cohort, the MELD score and TPMT/height were significantly associated with mortality. The discrimination of a score combining MELD and TPMT/height (MELD-psoas) was 0.84 (95% CI, 0.62-0.95). In the MELD-era, TPTM/height was significantly associated with mortality, independent of the MELD and MELD-Na scores. There was a 15% increase in mortality risk per unit decrease in TPMT/height. The discrimination of MELD-psoas score (0.82; 95% CI, 0.64-0.93) was superior to that of the MELD score and similar to that of the MELD-Na score. In patients with refractory ascites, mortality was significantly higher when TPMT/height was <16.8 mm/m (42% vs. 9%, p=0.02). CONCLUSIONS TPMP/height on CT at the level of the umbilicus, an objective marker of muscle waste, may be predictive of mortality in cirrhotic patients, independent of the MELD and MELD-Na scores. It may help to better assess the prognosis of patients with refractory ascites.
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