Letter: enteral nutrition in advanced cirrhosis - a case of missing the boat?

Aggressive nutrition intervention reduces ascites and frequency of paracentesis in malnourished patients with cirrhosis and ascites

Background and Aim

Alterations in nutrient metabolism, nutritional requirements, and reduced dietary intakes are common in chronic liver disease (CLD). These result in malnutrition, sarcopenia, and exacerbate progression to decompensation and ascites. We aimed to investigate the effects of continuous tube feeding (TF) on nutritional status and levels of ascites in malnourished individuals with decompensated cirrhosis.

Methods

Fourteen malnourished patients with decompensated cirrhosis and ascites who failed to respond to standard oral nutritional interventions received supplementary continuous nasogastric TF for 7 ± 1 weeks. Liver disease severity was assessed by model for end‐stage liver disease (MELD) and Child–Turcotte–Pugh (CTP) scores.

Results

Continuous TF occurred at home for 7 weeks (1.5–12 weeks). Prior to feeding, 12 patients had severe ascites, 10 required paracentesis, and 13 were severely malnourished. At completion of TF, five patients did not have ascites, four had mild ascites, four had moderate ascites, and only one had severe ascites and 10 no longer required paracentesis (P < 0.001). Median patient survival was 26 ± 7 months. Five survived to transplantation and three remained transplant‐free at 8, 1.9, and 1.7 years. Seven patients were moderately malnourished at completion of TF with an overall improvement in hand grip strength from 51% to 65% of predicted (P = 0.02).

Conclusion

Supplementary continuous TF may help to reduce ascites and paracentesis requirements and improve nutritional status. Supplementary continuous TF should be considered as a treatment for malnourished patients with decompensated cirrhosis and refractory ascites.

Enteral Nutrition in Chronic Liver Disease: Translating Evidence Into Practice

Malnutrition is prevalent in individuals with chronic liver disease and occurs as a result of inadequate nutrient intake, altered metabolism, and malabsorption. Although limited data show benefits of enteral nutrition (EN) in this population, patients with chronic liver disease often have inadequate oral intake and are potential candidates for EN. The goals of the EN, type and severity of liver disease, and access for EN will influence the decision to initiate EN. This paper summarizes EN studies in patients with liver disease and provides practical tips regarding patient selection, EN access, and EN formula choices. Two case studies illustrate the principles and challenges of providing EN to patients with cirrhosis. The paper concludes with suggested parameters for an EN feeding protocol and recommendations for future research.

Meta-analysis: oral or enteral nutritional supplementation in cirrhosis

BACKGROUND

Malnutrition is a common and clinically significant problem in patients with cirrhosis. The impact of nutritional therapy remains unclear.

AIM

To provide an up-to-date systematic review and meta-analysis of RCTs of oral or enteral nutritional supplementation (ONS or ENS) on nutritional and clinical outcomes in adult patients with cirrhosis.

METHODS

The primary outcome measure was survival. Included: full-text English language RCTs investigating ONS or ENS vs. a standard nonsupplemented diet in patients with cirrhosis. Excluded: parenteral or branched chain amino acids intervention; treatment duration ≤7 days, exclusive evaluation of posttransplant, postsurgical or quality of life outcomes.

RESULTS

Six trials (4 ONS/2 ENS) and 470 patients were included with 71% males and median age 53 years. When all studies were combined, there was no reduction in mortality [Relative risk (RR): 0.75 (0.42, 1.32), P = 0.31]. Subgroup analysis of 3 of the 4 ONS studies did demonstrate a mortality reduction [RR: 0.40 (0.18, 0.90), P = 0.03]. Of the 2 ENS studies, one included the sickest patients in the meta-analysis (82% Child Pugh C) and the other had the shortest mean intervention duration (8.6 days), possibly impacting the potential for benefit. Study quality was suboptimal (median Jadad = 2).

CONCLUSIONS

Although there is insufficient evidence to definitively state that oro-enteral nutritional supplementation impacts clinical outcomes, on the basis of this analysis, one can be cautiously optimistic that there is the potential for benefit without an increase in adverse events. Adequately powered, Child Pugh stratified studies of at least 1 month in duration are needed to clarify the impact on relevant clinical outcomes.