Assessment of nutritional status of patients waiting for liver transplantation

Mid-arm muscle circumference cutoff points in patients with cirrhosis: Low muscle mass related to malnutrition predicts mortality

OBJECTIVES

Muscle loss is one of the phenotypic criteria of malnutrition, is highly prevalent in patients with cirrhosis, and is associated with adverse outcomes. Mid-arm muscle circumference (MAMC) estimates the skeletal muscle mass and is especially helpful in cases of fluid overload. This study aimed to propose MAMC cutoff points for patients with cirrhosis and demonstrate its association with 1-year mortality.

METHODS

This is an analysis of cohort databases from five reference centers in Brazil that included inpatients and outpatients with cirrhosis aged ≥18 y. The nutritional variables obtained were the MAMC (n = 1075) and the subjective global assessment (n = 629). We established the MAMC cutoff points stratified by sex based on the subjective global assessment as a reference standard for malnutrition diagnosis, considering the sensitivity, specificity, and Youden index. An adjusted Cox regression model was used to test the association of MAMC cutoff points and 1-year mortality.

RESULTS

We included 1075 patients with cirrhosis, with a mean age of 54.8 ± 11.3 y; 70.4% (n = 757) male. Most patients had alcoholic cirrhosis (47.1%, n = 506) and were classified as Child-Pugh B (44.7%, n = 480). The MAMC cutoff points for moderate and severe depletion were ≤21.5 cm and ≤24.2 cm; ≤20.9 cm and ≤22.9 cm for women and men, respectively. According to these cutoff points, 13.8% (n = 148) and 35.1% (n = 377) of the patients had moderate or severe MAMC depletion, respectively. The 1-year mortality rate was 17.3% (n = 186). In the multivariate analysis adjusted for sex, age, MELD-Na, and Child-Pugh scores, a severe depletion in MAMC was an independent increased risk factor for 1-year mortality (HR: 1.71, 95% CI: 1.24-2.35, P < 0.001). Each increase of 1 cm in MAMC values was associated with an 11% reduction in 1-year mortality risk (HR: 0.89, 95% CI: 0.85-0.94, P < 0.001).

CONCLUSIONS

Low MAMC classified according to the new cutoff points predicts mortality risk in patients with cirrhosis and could be used in clinical practice.

Advancements in nutritional diagnosis and support strategies during the perioperative period for patients with liver cancer

Liver cancer represents a grave hepatic condition and constitutes a significant global health concern. Surgical resection remains the principal therapeutic modality for liver cancer. Nevertheless, perioperative malnutrition exerts a notable impact on patients with liver cancer, emerging as an independent risk factor for disease mortality and adverse outcomes. Hence, precise nutritional diagnosis and timely nutritional support hold the potential to enhance therapeutic efficacy and quality of life for liver cancer patients. This study represents a meticulous foray into the literature, extracting data from PubMed, Web of Science, and EMBASE databases, with a focus on the past 5 years. It scrutinizes the impact of malnutrition on patients undergoing liver cancer surgery, the etiological underpinnings of malnutrition within this patient cohort, the critical assessment of perioperative nutritional status, and the strategic approaches to nutritional support. Utilizing rigorous inclusion and exclusion criteria, the amassed scholarly works are meticulously synthesized, methodically organized, and categorically elaborated upon. Ultimately, the authors propose the incorporation of a multidisciplinary nutrition management team during the perioperative period, comprising nutritionists, pharmacists, physicians, nurses, psychologists, and rehabilitation therapists, among other specialized professionals. Together, they collaborate to devise and implement personalized nutritional support plans, monitor patients' nutritional status, and make necessary adjustments as required. Through comprehensive management and intervention, improvements in the nutritional status of liver cancer patients can be achieved, thereby enhancing surgical success rates and facilitating postoperative recovery. It is believed that this manuscript will offer valuable insights to advance the nutritional management during the perioperative phase of liver cancer, aiding in ameliorating patients' nutritional status and treatment outcomes.

Effectiveness of different tools for malnutrition in the assessment of patients with cirrhosis

BACKGROUND

We aimed to evaluate the prevalence of malnutrition using traditional measures of nutritional assessments like body mass index (BMI), mid-arm circumference (MAC), triceps skin fold thickness (TSF), mid-arm muscle circumference (MAMC), hand grip strength (HGS) and subjective global assessments (SGA) among cirrhotic patients referred for liver transplantation (LT).

METHODS

The study was conducted among 215 cirrhotic patients referred for LT at a tertiary care hospital. Patients were enrolled between July 2021 and October 2022 to assess the prevalence of malnutrition. Patient's demographic details, clinical history, BMI using dry weight, MAMC, HGS, SGA score and disease severity were assessed.

RESULTS

Chronic alcoholism was the main causative factor for cirrhosis, followed by viral infection. 58% of cirrhotic patients were moderately to severely malnourished based on SGA, 12% were undernourished based on BMI, 91% had low MAC, and 94% had low HGS/muscle strength indicating malnutrition. Low MAC (p = 0.048) and SGA (p = 0.000) were associated with CTP - B and C class, and low MAC (p = 0.046), low TSF (p = 0.005), and SGA (p = 0.000), were associated with MELD Na score >15. Low MAC (p = 0.011) and SGA (P = 0.000) were associated with mortality, although 78% of patients had MAC within the normal range. A strong association exists between malnutrition and complications, liver disease severity, and death.

CONCLUSION

In patients with chronic liver diseases, SGA performed well as a good predictor of malnutrition, this might be because SGA analyzes various domains which can be affected in chronic liver disease. Assessing malnutrition early may help in initiating appropriate medical nutritional therapy.

Application of Global Leadership Initiative on Malnutrition criteria in patients with liver cirrhosis

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) criteria were published to build a global consensus on nutritional diagnosis. Reduced muscle mass is a phenotypic criterion with strong evidence to support its inclusion in the GLIM consensus criteria. However, there is no consensus regarding how to accurately measure and define reduced muscle mass in clinical settings. This study aimed to investigate the optimal reference values of skeletal muscle mass index for diagnosing sarcopenia and GLIM-defined malnutrition, as well as the prevalence of GLIM-defined malnutrition in hospitalized cirrhotic patients.

METHODS

This retrospective study was conducted on 1002 adult patients with liver cirrhosis between January 1, 2018, and February 28, 2022, at Beijing You-An Hospital, Capital Medical University. Adult patients with a clinical diagnosis of liver cirrhosis and who underwent an abdominal computed tomography (CT) examination during hospitalization were included in the study. These patients were randomly divided into a modeling group (cohort 1, 667 patients) and a validation group (cohort 2, 335 patients). In cohort 1, optimal cut-off values of skeletal muscle index at the third lumbar skeletal muscle index (L3-SMI) were determined using receiver operating characteristic analyses against in-hospital mortality in different gender groups. Next, patients in cohort 2 were screened for nutritional risk using the Nutritional Risk Screening 2002 (NRS-2002), and malnutrition was diagnosed by GLIM criteria. Additionally, the reference values of reduced muscle mass in GLIM criteria were derived from the L3-SMI values from cohort 1. Multivariate logistic regression analysis was used to analyze the association between GLIM-defined malnutrition and clinical outcomes.

RESULTS

The optimal cut-off values of L3-SMI were 39.50 cm 2 /m 2 for male patients and 33.06 cm 2 /m 2 for female patients. Based on the cut-off values, 31.63% (68/215) of the male patients and 23.3% (28/120) of the female patients had CT-determined sarcopenia in cohort 2. The prevalence of GLIM-defined malnutrition in cirrhotic patients was 34.3% (115/335) and GLIM-defined malnutrition was an independent risk factor for in-hospital mortality in patients with liver cirrhosis ( Wald = 6.347, P  = 0.012).

CONCLUSIONS

This study provided reference values for skeletal muscle mass index and the prevalence of GLIM-defined malnutrition in hospitalized patients with liver cirrhosis. These reference values will contribute to applying the GLIM criteria in cirrhotic patients.

Global Leadership Initiative on Malnutrition criteria for the diagnosis of malnutrition and prediction of mortality in patients awaiting liver transplant: A validation study

OBJECTIVES

The Global Leadership Initiative on Malnutrition (GLIM) is a framework aiming to standardize malnutrition diagnosis. However, it still needs to be validated, in particular for patients with chronic liver disease. This study aimed to validate the GLIM criteria in patients with liver cirrhosis awaiting liver transplant (LTx).

METHODS

This was a retrospective observational study carried out with adult patients on the waiting list for LTx, consecutively evaluated between 2006 and 2021. The phenotypic criteria were unintentional weight loss, low body mass index, and reduced muscle mass (midarm muscle circumference [MAMC]). The etiologic criteria were high Model for End-Stage Liver Disease (MELD) and MELD adjusted for serum sodium (MELD-Na) scores, the Child-Pugh score, low serum albumin, and low food intake and/or assimilation. Forty-three GLIM combinations were tested. Sensitivity (SE), specificity (SP), positive and negative predictive values, and machine learning (ML) techniques were used. Survival analysis with Cox regression was carried out.

RESULTS

A total of 419 patients with advanced liver cirrhosis were included (median age, 52.0 y [46-59 y]; 69.2% male; 68.8% malnourished according to the Subjective Global Assessment [SGA]). The prevalence of malnutrition by the GLIM criteria ranged from 3.1% to 58.2%, and five combinations had SE or SP >80%. The MAMC as a phenotypic criterion with MELD and MELD-Na as etiologic criteria were predictors of mortality. The MAMC and the presence of any phenotypic criteria associated with liver disease parameters and low food intake or assimilation were associated with malnutrition prediction in ML analysis.

CONCLUSIONS

The MAMC and liver disease parameters were associated with malnutrition diagnosis by SGA and were also predictors of 1-y mortality in patients with liver cirrhosis awaiting LTx.

From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients

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.

Sarcopenia in chronic viral hepatitis: From concept to clinical relevance

Although the frequency of metabolic risk factors for cirrhosis and hepatocellular carcinoma (HCC) is increasing, chronic hepatitis B (CHB) and chronic hepatitis C (CHC) remain the most relevant risk factors for advanced liver disease worldwide. In addition to liver damage, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are associated with a myriad of extrahepatic manifestations including mixed cryoglobulinaemia, lymphoproliferative disorders, renal disease, insulin resistance, type 2 diabetes, sicca syndrome, rheumatoid arthritis-like polyarthritis, and autoantibody production. Recently, the list has grown to include sarcopenia. Loss of muscle mass or muscle function is a critical feature of malnutrition in cirrhotic patients and has been found in approximately 23.0%-60.0% of patients with advanced liver disease. Nonetheless, among published studies, there is significant heterogeneity in the aetiologies of hepatic diseases and measurement methods used to determine sarcopenia. In particular, the interaction between sarcopenia, CHB and CHC has not been completely clarified in a real-world setting. Sarcopenia can result from a complex and multifaceted virus-host-environment interplay in individuals chronically infected with HBV or HCV. Thus, in the present review, we provide an overview of the concept, prevalence, clinical relevance, and potential mechanisms of sarcopenia in patients with chronic viral hepatitis, with an emphasis on clinical outcomes, which have been associated with skeletal muscle loss in these patients. A comprehensive overview of sarcopenia in individuals chronically infected with HBV or HCV, independent of the stage of the liver disease, will reinforce the necessity of an integrated medical/nutritional/physical education approach in the daily clinical care of patients with CHB and CHC.

Predicting dry weight in patients with cirrhotic ascites undergoing large-volume paracentesis

BACKGROUND & AIMS

Ascites impairs the correct diagnosis and nutritional management in patients with cirrhosis, because the body weight, which is needed for nutritional assessment and calculation of nutritional needs, is overestimated. To adjust the weight in patients with ascites, dietetic guidances indicate substracting 2.2-14 kg or 5-15% of the measured body weight according to the degree of ascites, however, there is a lack of evidence to substantiate these values. The aim of this study was to develop new prediction equations to estimate the dry weight, comparing them with the currently used weight adjustments in patients with refractory cirrhotic ascites.

METHODS

Cross-sectional study, that included patients with decompensated cirrhosis undergoing large-volume paracentesis. Patients were submitted to nutritional risk screening, nutritional assessment, and anthropometric measurements that included body weight, abdominal circumference (both measured before and after paracentesis) height, and upper mid-arm circumference. The volume of ascitic fluid drained was also registered. For the predictions of dry weight, linear regression models were performed using as predictor variables: height, pre-paracentesis weight, pre-paracentesis abdominal circumference, or mid-upper arm circumference, and as response variable: post-paracentesis weight. The capacity of these models to predict the post-paracentesis weight was evaluated by comparing it with the currently used predictions through the intraclass correlation coefficient (ICC) and the mean squared error (MSE).

RESULTS

Nineteen patients were included, 15 male, and 18 with high nutritional risk and malnutrition. The difference between post-paracentesis weight and pre-paracentesis weight was -5.0 (-3.6 to -9.9) kg, similar to ascitic fluid volume drained. Two equations were developed to predict post-paracentesis weight. ICC values showed that both prediction equations were strongly correlated (r > 0.94) with post-paracentesis weight. Our models also showed lower MSEs (<17.97), compared with the current predictions (MSEs <64.19, when the pre-paracentesis weight is adjusted from absolute values and MSEs <33.24 when adjusted from percentage values), indicating a more accurate prediction.

CONCLUSION

The predictive equations from this study may be better options for dry weight estimation in patients with refractory cirrhotic ascites since they showed higher reliability compared to the currently used weight adjustment. External validation in a larger sample is still needed to confirm the clinical applicability of these equations.

Comparison of the GLIM criteria with specific screening tool for diagnosing malnutrition in hospitalized patients with cirrhosis: A descriptive cross-sectional study

BACKGROUND

The Global Leadership Initiative on Malnutrition (GLIM) has been built to diagnose malnutrition; however, its validity among patients with cirrhosis remains enigmatic. We aimed to investigate the prevalence of malnutrition according to GLIM criteria and compare the differences by using a specific screening tool.

METHODS

We conducted a descriptive cross-sectional study analyzing hospitalized patients. The Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) was chosen as the screening tool. Estimated prevalence was shown with and without the initial screening process. Diverse combinations of phenotypic and etiologic criteria and distinct body mass index (BMI) cutoffs were applied to detect frequency of malnourished patients with cirrhosis.

RESULTS

Overall, 363 patients were recruited (median age, 64 years; 51.2% female). The prevalence of malnutrition according to GLIM criteria with and without RFH-NPT screening was 33.3% and 36.4%, respectively. Low BMI and inflammation represented the most prevalent combination resulting in a malnutrition diagnosis (42.4%), followed by low BMI and reduced food intake (39.4%). By contrast, the least prevalence was found when combining reduced muscle mass with inflammation to diagnose malnutrition. Furthermore, the frequency of malnourished and well-nourished participants was not statistically different when using divergent BMI reference values across the study population.

CONCLUSIONS

GLIM criteria may serve a specific proxy to diagnose malnutrition, along with RFH-NPT screening. Relevant investigation is required to report on the applied combination of phenotypic/etiologic criteria, taking into consideration the marked impact of different models. More attempts are warranted to delineate the prognostic role of GLIM criteria in the context of cirrhosis.

Nutritional assessment in patients with liver cirrhosis

Malnutrition is a liver cirrhosis complication affecting more than 20%-50% of patients. Although the term can refer to either nutrient deficiency or excess, it usually relates to undernutrition in cirrhosis settings. Frailty is defined as limited physical function due to muscle weakness, whereas sarcopenia is defined as muscle mass loss and an advanced malnutrition stage. The pathogenesis of malnutrition in liver cirrhosis is multifactorial, including decreased oral intake, maldigestion/malabsorption, physical inactivity, hyperammonemia, hypermetabolism, altered macronutrient metabolism and gut microbiome dysbiosis. Patients with chronic liver disease with a Body Mass Index of < 18.5 kg/m² and/or decompensated cirrhosis or Child-Pugh class C are at the highest risk of malnutrition. For patients at risk of malnutrition, a detailed nutritional assessment is required, typically including a history and physical examination, laboratory testing, global assessment tools and body composition testing. The latter can be done using anthropometry, cross-sectional imaging including computed tomography or magnetic resonance, bioelectrical impedance analysis and dual-energy X-ray absorptiometry. A multidisciplinary team should screen for and treat malnutrition in patients with cirrhosis. Malnutrition and sarcopenia are associated with an increased risk of complications and a poor prognosis in patients with liver cirrhosis; thus, it is critical to diagnose these conditions early and initiate the appropriate nutritional therapy. In this review, we describe the prevalence and pathogenesis of malnutrition in liver cirrhosis patients and discuss the best diagnostic approach to nutritional assessment for them.

Different combinations of the GLIM criteria for patients awaiting a liver transplant: Poor performance for malnutrition diagnosis but a potentially useful prognostic tool

BACKGROUND & AIMS

Studies using the Global Leadership Initiative on Malnutrition (GLIM) criteria for patients with liver cirrhosis are limited. This study aimed to assess the impact of malnutrition according to the GLIM criteria on the outcomes of patients awaiting a liver transplant (LTx) and compare these criteria with Subjective Global Assessment (SGA).

METHODS

This retrospective observational study included adult patients awaiting LTx. Patient clinical data, nutritional status according to various tools including SGA, and resting energy expenditure were assessed. The distinct phenotypic and etiologic criteria provided 36 different GLIM combinations. The GLIM criteria and SGA were compared using the kappa coefficient. The variables associated with mortality before and after the LTx and with a longer length of stay (LOS) after LTx (≥18 days) were assessed by Cox regression and logistic regression analyses, respectively.

RESULTS

A total of 152 patients were included [median age 52.0 (interquartile range: 46.5-59.5) years; 66.4% men; 63.2% malnourished according to SGA]. The prevalence of malnutrition according to the GLIM criteria ranged from 0.7% to 30.9%. The majority of the GLIM combinations exhibited poor agreement with SGA. Independent predictors of mortality before and after LTx were presence of ascites or edema (p = 0.011; HR:2.58; CI95%:1.24-5.36), GLIM 32 (PA-phase angle + MELD) (p = 0.026; HR:2.08; CI95%:1.09-3.97), GLIM 33 (PA + MELD-Na≥12) (p = 0.018; HR:2.17; CI95%:1.14-4.13), and GLIM 34 (PA + Child-Pugh) (p = 0.043; HR:1.96; CI95%:1.02-3.77). Malnutrition according to GLIM 28 (handgrip strength + Child-Pugh) was independently associated with a longer LOS (p = 0.029; OR:7.21; CI95%:1.22-42.50).

CONCLUSION

The majority of GLIM combinations had poor agreement with SGA, and 4 of the 36 GLIM combinations were independently associated with adverse outcomes.

Sarcopenia as a prognostic predictor of liver cirrhosis: a multicentre study in China

BACKGROUND

Diagnostic criteria for sarcopenia have not been established in Chinese. This study established criteria based on the L3-skeletal muscle index (L3-SMI) and assessed its value for outcomes predicting in cirrhotic Chinese patients.

METHODS

Totally 911 subjects who underwent a CT scan at two centres were enrolled in Cohort 1 (394 male and 417 female subjects, aged 20-80 years). The data of those subjects younger than 60 years (365 male and 296 female subjects) were used to determine the reference intervals of the L3-SMI and its influencing factors. Cohort 2 consisted of 480 patients (286 male and 184 female patients) from three centres, and their data were used to investigate the prevalence of sarcopenia and evaluate the value of L3-SMI for predicting the prognosis and complications of cirrhosis.

RESULTS

Age and sex had the greatest effects on the L3-SMI (P < 0.001). The L3-SMI scores were clearly higher in male patients than in female patients (52.94 ± 8.41 vs. 38.91 ± 5.65 cm² /m² , P < 0.001) and sharply declined in subjects aged ≥ 60 years. Based on the mean -1.28 × SD among adults aged < 60 years, the L3-SMI cut-off value for sarcopenia was 44.77 cm² /m² in male patients and 32.50 cm² /m² in female patients. Using these values, 22.5% of the cirrhotic patients (28.7% of male patients and 11.9% of female patients) were diagnosed with sarcopenia. Compared with non-sarcopenia individuals, sarcopenia patients had lower body mass index (21.28 ± 3.01 vs. 24.09 ± 3.39 kg/m² , P < 0.001) and serum albumin levels (31.54 ± 5.93 vs. 32.93 ± 5.95 g/L, P = 0.032), longer prothrombin times (16.39 ± 3.05 vs. 15.71 ± 3.20 s, P = 0.049), higher total bilirubin concentrations (41.33 ± 57.38 vs. 32.52 ± 31.48 μmol/L, P = 0.039), worse liver function (Child-Pugh score, 8.05 ± 2.11 vs. 7.32 ± 2.05, P = 0.001), higher prevalence of cirrhosis-related complications (81.82% vs. 62.24%, P < 0.001) and mortality (30.68% vs. 11.22%, P < 0.001). Overall survival was significantly lower in the sarcopenia group [risk ratio (RR) = 2.643, 95% confidence interval (CI) 1.646-4.244, P < 0.001], accompanied with an increased cumulative incidence of ascites (RR = 1.827, 95% CI 1.259-2.651, P = 0.002), spontaneous bacterial peritonitis (RR = 3.331, 95% CI 1.404-7.903, P = 0.006), hepatic encephalopathy (RR = 1.962, 95% CI 1.070-3.600, P = 0.029), and upper gastrointestinal varices (RR = 2.138, 95% CI 1.319-3.466, P = 0.002). Subgroup analysis showed sarcopenia shortened the survival of the patients with Model For End-Stage Liver Disease score > 14 (RR = 4.310, 95% CI 2.091-8.882, P < 0.001) or Child-Pugh C (RR = 3.081, 95% CI 1.516-6.260, P = 0.002).

CONCLUSIONS

Sarcopenia is a common comorbidity of cirrhosis and can be used to predict cirrhosis-related complications and the prognosis.

Bioelectrical impedance vector analysis in patients on the waiting list for liver transplant: Associated factors and prognostic effects

OBJECTIVES

The aim of this study was to assess patients on the waiting list for liver transplant (LTx) according to bioelectrical impedance vector analysis (BIVA), as well as to verify the association between the placement of the vectors on the graph with clinical outcomes and identify the predictors to vector placement in quadrant 4 (Q4; indicating more hydration and less cellularity).

METHODS

This was a retrospective observational study including 129 patients ≥20 y of age awaiting LTx. Patients' nutritional status was assessed by using different tools, including single-frequency bioelectrical impedance analysis and the Subjective Global Assessment (SGA). Clinical data were registered. The BIVA was evaluated by comparing the individual vectors plotted for all patients to the tolerance ellipses of 50%, 75%, and 95% of the reference healthy population. The quadrant of the vector for each patient was registered.

RESULTS

The majority of the vectors were placed in Q1 (n = 54; 41.9%) and Q4 (n = 39; 30.2%). The presence of ascites or edema (hazard ratio [HR], 2.43; 95% confidence interval [CI], 1.15-5.12; P = 0.019) and the BIVA vector placed in Q4 in any ellipse (HR, 2.10; 95% CI, 1.07-4.09; P = 0.029) were independent predictors for mortality on the waiting list or ≤1 y after LTx. BIVA was not associated with longer hospital length of stay. The predictors of vector placement in Q4 were higher age, malnutrition according to SGA, and presence of ascites or edema.

CONCLUSION

Patients on the waiting list for LTx with BIVA vectors placed in Q4, in the 50%, 75%, or 95% tolerance ellipses, presented a worse prognosis.

Liver function and energy metabolism in hepatocellular carcinoma developed in patients with hepatitis B-related cirrhosis

Energy metabolism in patients with Hepatocellular carcinoma (HCC) accompanying by hepatitis B cirrhosis is unknown.To compare the differences in liver functions and energy metabolism between patients with hepatitis B-related cirrhosis and patients with HCC.This was a retrospective study of patients with hepatitis B-related cirrhosis (LC group, n = 75) and patients with HCC accompanying by hepatitis B cirrhosis (HCC group, n = 80) treated in Beijing You'an Hospital between January 2013 and June 2017. The resting energy expenditure (REE), respiratory quotient (RQ), carbohydrate oxidation rate (CHO%), fat oxidation rate (FAT%), and protein oxidation rate (PRO%) were measured using a metabolic cart. Liver function, renal function, blood coagulation, etc. were collected.Compared to the LC group, patients with HCC had normal metabolism, but RQ (0.83 ± 0.07 vs 0.85 ± 0.08, P = .073) and CHO% (35.5% vs 49%, P = .013) were lower and FAT% was higher (41% vs 33%, P = .030). Compared with patients with LC group, albumin (ALB), γ-glutamyltranspeptadase (GGT), alkaline phosphatase (AKP), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and prothrombin time activity (PTA) were elevated in the HCC group, while total bilirubin (TB), total bile acid (TBA), and international normalized ratio (INR) were reduced (P < .05). Cholinesterase (CHE) was positively correlated with RQ, CHO, and CHO% (P < .05), while negatively correlated with FAT and FAT% (P < .05). AKP was negatively correlated with RQ, CHO, and CHO% (P < .05), while positively correlated with FAT and FAT% (P < .05). TBA was negatively correlated with RQ and CHO (P < .05), while positively correlated with FAT (P < .05).HCC leads to increased liver synthetic function and improve the liver functions of patients with LC, at least to some extent, but the nutritional metabolism was poor.

EASL Clinical Practice Guidelines on nutrition in chronic liver disease

A frequent complication in liver cirrhosis is malnutrition, which is associated with the progression of liver failure, and with a higher rate of complications including infections, hepatic encephalopathy and ascites. In recent years, the rising prevalence of obesity has led to an increase in the number of cirrhosis cases related to non-alcoholic steatohepatitis. Malnutrition, obesity and sarcopenic obesity may worsen the prognosis of patients with liver cirrhosis and lower their survival. Nutritional monitoring and intervention is therefore crucial in chronic liver disease. These Clinical Practice Guidelines review the present knowledge in the field of nutrition in chronic liver disease and promote further research on this topic. Screening, assessment and principles of nutritional management are examined, with recommendations provided in specific settings such as hepatic encephalopathy, cirrhotic patients with bone disease, patients undergoing liver surgery or transplantation and critically ill cirrhotic patients.

Nomogram and Validity of a Model for Predicting Malnutrition in Patients on Liver Transplant Lists

BACKGROUND

Malnutrition is associated with increased morbimortality in liver transplant patients, and it is important to identify factors related to nutritional status in these patients.

AIMS

Determine variables associated with malnutrition and create a nomogram in liver transplant candidates.

METHODS

Cross-sectional study (n = 110).

VARIABLES

demographic variables, imbalances due to the disease, transplant aetiology and analytical parameters. Physical examination was performed and degree of hepatic dysfunction calculated. Nutritional status was assessed: Controlling Nutritional Status, Spanish Society of Parenteral and Enteral Nutrition criteria, Nutritional Risk Index, Prognostic Nutritional Index or Onodera Index and The Subjective Global Assessment. Logistic regression analysis was performed. A predictive nomogram (discrimination and calibration analysis) was generated.

RESULTS

Malnourishment was defined according to at least 4 or more of the methods studied. Patients with ascites, encephalopathy and portal hypertension presented malnourishment more frequently. Malnutrition was associated with greater liver dysfunction and lower grip strength. Variables independently associated with malnourishment were encephalopathy and lower albumin values. A nomogram was created to predict malnourishment, with good discriminatory power and calibration.

CONCLUSIONS

A score was developed for evaluating malnutrition risk. This would provide a tool that makes it possible to quickly and easily identify the risk of malnutrition in liver transplant candidates.

Nutrition Screening vs Nutrition Assessment: What's the Difference?

Screening and assessment imply different processes, with the former indicating risk factors for a deprived nutrition condition and the latter providing the nutrition diagnosis. Both should be routinely performed at hospital admission according to recommended guidelines; however, this is not the reality worldwide, and undernutrition remains highly prevalent in the hospital setting. Therefore, the objective of the current review is to delve into the principles leading to nutrition status deficiencies and how they should be addressed by screening and assessment. A critical appraisal for the reasons associated with the misunderstanding between screening and assessing is proposed without further discussing the many available screening tools while approaching some of the assessment instruments.

Subjective Global Assessment and Handgrip Strength as Predictive Factors in Patients with Liver Cirrhosis

Background and Aims

Malnutrition is common in patients with chronic liver disease. We aimed to evaluate malnutrition assessment tools in predicting severity and survival of patients with liver cirrhosis.

Material and Methods

We examined patients with liver cirrhosis. Nutritional evaluation was performed on admission, using subjective global assessment (SGA), handgrip strength (HGS), and anthropometry. Patients were followed up for 6 months.

Results

We included 100 patients, 72 men, with mean age of 59.2 years. According to disease severity, patients were 23% Child-Pugh A, 46% Child-Pugh B, and 31% Child-Pugh C. SGA and HGS significantly correlated with Child-Pugh, MELD, and MELD-Na scores on admission. At 6 months follow-up, 80.4% (78 of 97) of patients survived, while 3 patients were lost from observation. Survival was predicted by SGA (1 death in 32 patients SGA A, 8 deaths in 46 patients SGA B, and 9 deaths in 19 patients SGA C, p = 0.001) and HGS (25.1 ± 8.5 in deceased versus 30.6 ± 10.9 in survivors, p = 0.046). The mean BMI and MAMC values did not significantly differ between patients who survived or were deceased at 6 months.

Conclusion

HGS and SGA may predict severity and short-term survival in cirrhotic patients.

Body composition assessed by dual-energy X-ray absorptiometry predicts early infectious complications after liver transplantation

BACKGROUND

It is challenging to identify malnutrition, which is a risk factor for poor outcome in patients with liver cirrhosis. In the present study, we aimed to investigate the prevalence of malnutrition among patients listed for liver transplantation, as assessed by different methods, and also to relate dual-energy X-ray absorptiometry (DXA) to short-term post-transplant outcomes.

METHODS

In this retrospective cohort study, we reviewed the medical records of 106 patients who underwent liver transplantation in 2009-2012. Body composition was assessed by the fat-free mass index (FFMI) and fat mass index (FMI) obtained using DXA. Severe infections within 1 month, length of stay in intensive care unit and length of hospital stay were endpoints of primary interest.

RESULTS

The prevalence of malnutrition was 2-20% depending on sex and the assessment method. Thirty-nine (37%) patients developed severe infections within 1 month after liver transplantation. In multivariate analysis with logistic regression, body composition was significantly associated with post-operative infection when measured with FFMI (P = 0.043) but not with FMI (P = 0.087). Post-operative dialysis (P = 0.004) and post-operative infections (P < 0.001) were significantly associated with length of stay in hospital. Post-operative bleeding (P = 0.015), duration of mechanical ventilation (P < 0.001) and the need for dialysis (P < 0.001), but not body composition, were significant predictors of the length of stay in the intensive care unit.

CONCLUSIONS

The prevalence of malnutrition depends on assessment method. FFMI is an independent predictor for early post-transplant infections. Body composition measured by DXA during the pretransplant evaluation provides valuable information about nutritional status in patients with liver cirrhosis.

Nutrition assessment and its effect on various clinical variables among patients undergoing liver transplant

BACKGROUND

Malnutrition is highly prevalent in patients undergoing liver transplantation and has been associated to various clinical variables and outcome of the surgery.

METHODS

We recruited 54 adult patients undergoing living donor liver transplant (LT) as study sample. Nutrition assessment was performed by body mass index (BMI), BMI for ascites, albumin, subjective global assessment (SGA) and anthropometry [mid upper arm circumference (MUAC), mid arm muscle circumference (MAMC), and triceps skin-fold (TSF)], Hand Grip strength, and phase angle of the body. Prevalence and comparison of malnutrition was performed with various clinical variables: aetiology, Child Turcotte Pugh scores and model for end stage liver disease (ESLD) grades, degree of ascites, blood product usage, blood loss during the surgery, mortality, days [intensive care unit (ICU), Ventilator and Hospital], and Bio-impedance analysis [weight, fat mass, fat free mass (FFM), muscle mass and body fat%].

RESULTS

Assessment of nutrition status represents a major challenge because of complications like fluid retention, hypoalbuminemia and hypoproteinemia. Different nutrition assessment tools show great disparity in the level of malnutrition among ESLD patients. In the present study recipient nutrition status evaluation by different nutrition assessment tools used showed malnutrition ranging from 3.7% to 100%. BMI and anthropometric measurements showed lower prevalence of malnutrition than phase angle and SGA whereas hand grip strength showed 100% malnutrition. Agreement among nutrition assessment methods showed moderate agreement (κ=0.444) of SGA with phase angle of the body. Malnutrition by different assessment tools was significantly associated to various clinical variables except MELD and days (ICU, Ventilator and Hospital). SGA was significantly (P<0.05) associated to majority of the clinical variables like aetiology, child Turcotte Pugh grades, degree of ascites, blood product usage, blood loss during the surgery, BIA (fat mass, FFM, muscle mass and body fat%).

CONCLUSIONS

The different nutrition assessment tools showed great variability of results. SGA showed moderate agreement with phase angle of the body and was associated with various clinical and prognostic variables of liver transplantation.

Nutrition therapy: Integral part of liver transplant care

Managing malnutrition before liver transplantation (LTx) while on the waiting list and, excessive weight gain/metabolic disturbances in post-surgery are still a challenge in LTx care. The aim of this review is to support an interdisciplinary nutrition approach of these patients. Cirrhotic patients are frequently malnourished before LTx and this is associated with a poor prognosis. Although the relation between nutritional status versus survival, successful operation and recovery after LTx is well established, prevalence of malnutrition before the operation is still very high. Emerging research has also demonstrated that sarcopenia pre and post-transplant is highly prevalent, despite the weight gain in the postoperative period. The diagnosis of the nutritional status is the first step to address the adequate nutritional therapy. Nutritional recommendations and therapy to manage the nutritional status of LTx patients are discussed in this review, regarding counseling on adequate diets and findings of the latest research on using certain immunonutrients in these patients (branched chain amino-acids, pre and probiotics). Nutrition associated complications observed after transplantation is also described. They are commonly related to the adverse effects of immunosuppressive drugs, leading to hyperkalemia, hyperglycemia and weight gain. Excessive weight gain and post-transplant metabolic disorders have long been described in post-LTx and should be addressed in order to reduce associated morbidity and mortality.

Nutritional care in hospitalized patients with chronic liver disease

AIM: To evaluate the practice of nutritional assessment and management of hospitalised patients with cirrhosis and the impact of malnutrition on their clinical outcome.

METHODS: This was a retrospective cohort study on patients with liver cirrhosis consecutively admitted to the Department of Gastroenterology and Hepatology at the Royal Adelaide Hospital over 24 mo. Details were gathered related to the patients’ demographics, disease severity, nutritional status and assessment, biochemistry and clinical outcomes. Nutritional status was assessed by a dietician and determined by subjective global assessment. Estimated energy and protein requirements were calculated by Simple Ratio Method. Intake was estimated from dietary history and/or food charts, and represented as a percentage of estimated daily requirements. Median duration of follow up was 14.9 (0-41.4) mo.

RESULTS: Of the 231 cirrhotic patients (167 male, age: 56.3 ± 0.9 years, 9% Child-Pugh A, 42% Child-Pugh B and 49% Child-Pugh C), 131 (57%) had formal nutritional assessment during their admission and 74 (56%) were judged to have malnutrition. In-hospital caloric (15.6 ± 1.2 kcal/kg vs 23.7 ± 2.3 kcal/kg, P = 0.0003) and protein intake (0.65 ± 0.06 g/kg vs 1.01 ± 0.07 g/kg, P = 0.0003) was significantly reduced in patients with malnutrition. Of the malnourished cohort, 12 (16%) received enteral nutrition during hospitalisation and only 6 (8%) received ongoing dietetic review and assessment following discharge from hospital. The overall mortality was 51%, and was higher in patients with malnutrition compared to those without (HR = 5.29, 95%CI: 2.31-12.1; P < 0.001).

CONCLUSION: Malnutrition is common in hospitalised patients with cirrhosis and is associated with higher mortality. Formal nutritional assessment, however, is inadequate. This highlights the need for meticulous nutritional evaluation and management in these patients.

Update on malnutrition assessment in patients with liver cirrhosis

Liver cirrhosis is the terminal stage of chronic hepatitis, often accompanied by protein-caloric malnutrition (PCM). Many factors may be at play causing an individual with liver cirrhosis to develop malnutrition. Malnutrition is regarded as the important prognostic factor of cirrhosis and is the contraindication to liver transplantation. However, in clinical practice, physicians and nurses often do not detect the presence of malnutrition fully in the population with cirrhosis, nor do they realize its damaging consequences. As a consequence, malnutrition is often overlooked. Given all these, this review focuses on several aspects of nutritional assessment, on the basis of the latest research reports, aiming at having a comprehensive and up-to-date understanding concerning malnutrition in cirrhosis, as well as giving medical providers instructions to perform a clinical nutritional assessment more perfectly.

Reprint of: Nutrition in the Management of Cirrhosis and its Neurological Complications

Malnutrition is a common feature of chronic liver diseases that is often associated with a poor prognosis including worsening of clinical outcome, neuropsychiatric complications as well as outcome following liver transplantation. Nutritional assessment in patients with cirrhosis is challenging owing to confounding factors related to liver failure. The objectives of nutritional intervention in cirrhotic patients are the support of liver regeneration, the prevention or correction of specific nutritional deficiencies and the prevention and/or treatment of the complications of liver disease per se and of liver transplantation. Nutritional recommendations target the optimal supply of adequate substrates related to requirements linked to energy, protein, carbohydrates, lipids, vitamins and minerals. Some issues relating to malnutrition in chronic liver disease remain to be addressed including the development of an appropriate well-validated nutritional assessment tool, the identification of mechanistic targets or therapy for sarcopenia, the development of nutritional recommendations for obese cirrhotic patients and liver-transplant recipients and the elucidation of the roles of vitamin A hepatotoxicity, as well as the impact of deficiencies in riboflavin and zinc on clinical outcomes. Early identification and treatment of malnutrition in chronic liver disease has the potential to lead to better disease outcome as well as prevention of the complications of chronic liver disease and improved transplant outcomes.

Assessment of nutritional status and health-related quality of life before and after liver transplantation

Background

Patients with chronic liver disease frequently suffer from malnutrition, together with a decline in their health-related quality of life.

This study was carried out with the aim of evaluating the nutritional status, complications of medical and surgical care, anxiety, health-related quality of life and dependence level on basic and instrumental activities of daily living in pre- and post-liver transplant patients.

Methods/Design

A prospective observational study with follow-up of patients on the waiting list for liver transplants who subsequently received a transplant at the University Hospital Complex in A Coruña during the period 2012–2014 (n = 110).

All the patients will be followed-up for a maximum of 6 months. For survivors, assessments will be re-evaluated at one, three and six months post- transplant.

Informed consent of the patient and ethical review board approval was obtained (Code: 2010/081 and 2010/082).

The following variables will be studied: socio-demographic data, reason for the transplant, comorbidity (Charlson Score), analytical parameters, time on transplant waiting list and post-transplant complications. A trained nurse will evaluate the following for each patient: nutritional indices, anthropometric variables and handgrip strength. Validated questionnaires will be used to determine the patients’ nutritional status (Subjective Global Assessment), anxiety (STAI questionnaire), Health-Related Quality of Life (LDQoL 1.0 questionnaire), dependence (Barthel Index and Lawton-Brody Scale), nursing diagnoses (NANDA) and post-transplant quality indicators.

Multiple linear/logistic regression models will be used to identify variables associated with the events of interest. Changes in nutritional status, quality of life and dependence over time will be analysed with linear mixed-effects regression models.

Actuarial survival analysis using Kaplan-Meier curves, Cox regression and competitive risk will be performed

Concordance between the different scores that assess nutritional status and interobserver agreement regarding nursing diagnoses will be studied using the statistical Kappa index and Bland Altman method.

Discussion

The risk of malnutrition can be considered as a possible prognostic factor in transplant outcomes, associated with anxiety, health-related quality of life and dependence.

For this reason we consider interesting to perform a prospective follow-up study of patients who require a transplant to survive, studying their nutritional status and health-related quality of life.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-015-0232-3) contains supplementary material, which is available to authorized users.

Nutritional assessment and treatment in patients with liver cirrhosis

Liver cirrhosis is a worldwide disease with high morbidity. Patients with liver cirrhosis are often complicated with malnutrition, and nutritional status has close relationship with prognosis. Currently, there has been no unified standard to assess the nutrition status of patients with liver cirrhosis; several tools should be combined in order to generate more accurate evaluation. A reasonable nutritional intervention should be given to improve the prognosis of patients with cirrhosis. This review focuses on essential aspects in the nutritional assessment and support in cirrhotic patients to provide a basis for correctly assessing the patient's nutritional status and providing adequate nutritional treatment.

Nutrition assessment in patients undergoing liver transplant

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.

Nutrition status of patients with chronic hepatitis B or C

OBJECTIVE

Nutrition disorders in patients with chronic liver disease have become a recent concern because these disorders influence outcomes. We investigated patients' nutrition status, included consecutively in the last 2 years to the study, and related the results with the severity of liver disease.

METHODS

A total of 230 patients with hepatitis B (n = 80) or C (n = 150) were evaluated by the subjective global assessment (SGA) and body mass index (BMI). The risk of metabolic complications was assessed by waist circumference (WC) and the percentage of body fat (%BF). Alcohol abuse was defined as daily consumption >20 g and >30 g for women and men, respectively.

RESULTS

The mean age was 54 years, with 52.6% women, 75% patients without cirrhosis, and 15% patients with cirrhosis. According to the SGA, 86.5% of patients were nourished, and 13.5% were malnourished. Malnutrition was associated with cirrhosis (prevalence ratio [PR], 1.25; 95% confidence interval [CI], 1.1-1.4; P < .001), alcohol abuse, direct bilirubin >3.0 mg/dL, international normalized ratio >1.1, platelet <150 × 10(3)/mm(3), hemoglobin <12 g/dL, and serum albumin <3.5 g/dL (P < .05). According to the BMI, 43.9% of patients were eutrophic, 33.5% were overweight, 21.3% were obese, and 1.3% were underweight. Obese patients had a higher prevalence of steatosis than eutrophic (PR, 1.53; 95% CI, 1.15-2.04; P = .003) and overweight (PR, 1.71; 95% CI, 1.33-2.20; P < .001) patients. Overweight/obesity was associated with WC >94 cm (men) and >80 cm (women), %BF >25% (men) and >32% (women) (P < .01), triglyceride >150 mg/dL, high-density lipoprotein cholesterol <40 mg/dL, glucose >99 mg/dL, insulin >20 µU/mL, homeostatic model assessment-insulin resistance >3.2, and thyroid-stimulating hormone >2.5 µU/mL (P < .05).

CONCLUSIONS

Overweight/obesity is prevalent among patients with hepatitis B and C and can contribute to the development of steatosis. Malnutrition is also observed and is related to the severity of liver disease.

Nutrition in the management of cirrhosis and its neurological complications

Malnutrition is a common feature of chronic liver diseases that is often associated with a poor prognosis including worsening of clinical outcome, neuropsychiatric complications as well as outcome following liver transplantation. Nutritional assessment in patients with cirrhosis is challenging owing to confounding factors related to liver failure. The objectives of nutritional intervention in cirrhotic patients are the support of liver regeneration, the prevention or correction of specific nutritional deficiencies and the prevention and/or treatment of the complications of liver disease per se and of liver transplantation. Nutritional recommendations target the optimal supply of adequate substrates related to requirements linked to energy, protein, carbohydrates, lipids, vitamins and minerals. Some issues relating to malnutrition in chronic liver disease remain to be addressed including the development of an appropriate well-validated nutritional assessment tool, the identification of mechanistic targets or therapy for sarcopenia, the development of nutritional recommendations for obese cirrhotic patients and liver-transplant recipients and the elucidation of the roles of vitamin A hepatotoxicity, as well as the impact of deficiencies in riboflavin and zinc on clinical outcomes. Early identification and treatment of malnutrition in chronic liver disease has the potential to lead to better disease outcome as well as prevention of the complications of chronic liver disease and improved transplant outcomes.

Negative energy balance secondary to inadequate dietary intake of patients on the waiting list for liver transplantation

OBJECTIVES

The aim of this study was to evaluate the energy balance (EB) of patients on the waiting list for liver transplantation, using total energy expenditure (TEE) assessment and total caloric intake (TCI).

METHODS

We analyzed nutrient adequacy and factors associated with it. EB was obtained by subtracting the TCI (obtained by 3-d food record) from TEE, which was measured as resting energy expenditure and physical activity factor calculation. Socioeconomic and clinical data also were evaluated. Univariate and multiple linear regressions were used (P < 0.05). Seventy-three patients were included.

RESULTS

The TEE was 2318.5 kcal, and the TCI was 1485.1 kcal, with 81.6% of patients presenting with negative EB. There was no significant association between TCI and socioeconomic variables, medications, and encephalopathy (P > 0.05). Women, less-educated patients, those with ascites, and those who were malnourished presented with lower TCI (P < 0.05). Severity of disease, by Child-Pugh and Model for End-Stage Liver Disease scores were associated with EB (P < 0.05). Child-Pugh remained significant after multivariate analyses. Energy inadequacy was observed in 91.8% of patients, and protein inadequacy in 72.6% of patients. Polyunsaturated fatty acid (64.4%) and monounsaturated fatty acid (91.8%) and fiber (94.5%) inadequacies also were high. The percentage of adequate intake was less than 10% for vitamins B5 and D, calcium, folic acid, and potassium, and higher percentages of adequate intake (>80%) were found for iron and vitamins B1 and B12. Moreover, 54.8% and 16.4% of the patients had excessive sodium and cholesterol intakes, respectively.

CONCLUSION

Negative EB was highly prevalent among patients on the waiting list for liver transplantation, and was associated with the severity of liver disease. Negative EB was primarily affected by low food intake. The food intake data were characterized by low overall energy and protein intake and inadequate composition of the patient's diet plan, which tended to be characterized by specific nutrient deficiencies and excesses.

Overweight in liver transplant recipients

This review aims to describe the incidence and prevalence of overweight and obesity after liver transplantation and the consequences associated with it. Literature review consultation was conducted in Medline / PubMed, SciELO, EMBASE and LILACS, with the combination of the following keywords: liver transplantation, overweight, obesity, weight gain. Overweight is incident on more than 60% of patients undergoing liver transplantation and obesity rates exceed 20% in the first year after surgery, during which occurs the largest relative weight gain. Studies have shown that between 60% and 70% of patients undergoing liver transplantation are overweight after the third year, 90% with abdominal obesity. Associated factors are, among others, advanced age, family history of overweight and excess weight prior to liver disease. The contribution of immunosuppressive medication remains controversial. Some of the consequences of overweight are liver steatosis, steatohepatitis, diabetes mellitus, hypertension, dyslipidemia, cardiovascular disease and death.

Nutrition status and intestinal permeability in patients eligible for liver transplantation

BACKGROUND

Increased intestinal permeability has been reported in multiple studies of cirrhotic patients, although specific factors associated with this finding have not been fully elucidated. Thus, the aim of this study was to investigate whether there was an association between nutrition status measured by different methods and intestinal permeability in cirrhotic patients who were candidates for liver transplantation.

MATERIALS AND METHODS

The study group comprised 18 cirrhotic patients and 15 healthy controls. Patients' nutrition status was evaluated by Subjective Global Assessment (SGA), anthropometry, dynamometry, and phase angle, which was determined by bioelectrical impedance analysis. Intestinal permeability was assessed by the lactulose/mannitol test.

RESULTS

The prevalence of malnutrition showed wide variance between different assessment methods (5.5%-77.8%). Intestinal permeability was significantly higher in cirrhotic patients than in healthy controls. In relation to nutrition status, intestinal permeability and phase angle did not differ significantly between patients who were considered well nourished (median intestinal permeability, 0.010 [range, 0.001-0.198]; median phase angle, 6.0 [range, 4.2-6.9]) and malnourished patients (intestinal permeability, 0.032 [range, 0.002-0.079]; phase angle, 4.8 [range, 2.2-6.1]) by SGA. In addition, no correlation was found between nutrition diagnosis as assessed by different methods, patient age, liver disease severity scores, and laboratory measurements with intestinal permeability.

CONCLUSION

Although intestinal permeability was increased in cirrhotic patients, this finding was not associated with nutrition status.

Hyper- and hypometabolism are not related to nutritional status of patients on the waiting list for liver transplantation

BACKGROUND & AIMS

Metabolic disorders and malnutrition are well known conditions reported in patients with liver disease (LD), but the relationship between them are underexplored. So, the aim of this study was to assess the resting energy expenditure (REE) of these patients, identifying the prevalence of hyper- and hypometabolism. In addition, to evaluate whether malnutrition and clinical variables were associated with REE and metabolic disorders.

METHODS

The REE was measured by indirect calorimetry and predicted by the Harris and Benedict formula (REEHB). Nutritional status was assessed by different methods. The etiology, severity and complications of LD were also evaluated.

RESULTS

A total of 81 patients were assessed. The measured REE was 1587.5 ± 426.6 kcal. The REE was overestimated by the REEHB (REE:REEHB <0.8) in 7.4% and underestimated (REE:REEHB >1.2) in 24.7% of the patients. The REE was lower in malnourished patients (p < 0.05). However, hyper- and hypometabolism were not associated with nutritional status (p > 0.05). The REE and hypermetabolism were not associated with LD, but hypometabolic patients had a higher prevalence of Child C, and had higher values for MELD, INR and total bilirubin (p < 0.05). After multiple regression analyses, the REE was significantly associated (p < 0.05) with intracellular body water, arm muscle area and serum glucose. Serum glucose was only significantly associated (p < 0.05) with hypermetabolism, and INR with hypometabolism.

CONCLUSION

Changes in resting metabolism are present but not universal. The hypermetabolism was associated with extrahepatic factors, and hypometabolism with the severity of LD. Under these conditions in the clinical setting, calculated energy requirements using the HB formula should be adjusted.

Patient selection for liver transplantation

Improved outcomes in liver transplant recipients reflect advances in surgical technique, post-operative care, immunosuppression as well as better selection of potential candidates. The pre-transplant evaluation is a multidisciplinary process intended to recognize and treat important comorbid conditions that may impair outcomes during the peri- and post-transplant periods. Important psychosocial issues should also be ascertained and tackled early during the pre-transplant evaluation with an overarching intention to improve the success of liver transplantation.

Nutritional status of patients with alcoholic cirrhosis undergoing liver transplantation: time trends and impact on survival

Alcoholic cirrhotics evaluated for liver transplantation are frequently malnourished or obese. We analyzed alcoholic cirrhotics undergoing transplantation to examine time trends of nutrition/weight, transplant outcome, and effects of concomitant hepatitis C virus (HCV) and/or hepatocellular carcinoma (HCC). Nutrition and transplant outcomes were reviewed for alcoholic cirrhosis with/without HCV/HCC. Malnutrition was defined by subjective global assessment. Body mass index (BMI) classified obesity. A total of 261 patients receiving transplants were separated (1988-2000, 2001-2006, and 2007-2011) to generate similar size cohorts. Mean BMI for the whole cohort was 28 ± 6 with 68% classified as overweight/obese. Mean BMI did not vary among cohorts and was not affected by HCV/HCC. While prevalence of malnutrition did not vary among cohorts, it was lower in patients with HCV/HCC (P < 0.01). One-year graft/patient survival was 90% and not impacted by time period, HCV/HCC, or malnutrition after adjusting for demographics and model end-stage liver disease (MELD). Alcoholic cirrhotics undergoing transplantation are malnourished yet frequently overweight/obese. Among patients selected for transplantation, 1-year post-transplant graft/patient survival is excellent, have not changed over time, and do not vary by nutrition/BMI. Our findings support feasibility of liver transplantation for alcoholic cirrhotics with obesity and malnutrition.

Weight loss during cirrhosis is related to the etiology of liver disease

CONTEXT

Malnutrition is widely described in patients waiting for liver transplantation (LTx). However, risk factors associated with weight loss during liver disease have not yet been well studied.

OBJECTIVES

The aim of this study was to assess weight loss and its risk factors during liver disease and up to the first appointment after transplantation. Patients who underwent LTx were retrospectively assessed for weight loss during liver disease while on the waiting list for LTx. The usual weight of the patients before disease and their weight on the first outpatient appointment after transplant were considered. Demographic, socioeconomic, lifestyle and clinical variables were collected to assess risk factors using a linear regression analysis. We retrospectively evaluated 163 patients undergoing LTx between 1997 and 2008.

RESULTS

Patients lost in average 7.7 ± 12.4 kg while ill. Variables independently associated with weight loss by multiple linear regression analyses were as follows: former smoker (P = 0.03), greater body mass index (P<0.01), overweight before liver disease (P = 0.02) and indication for LTx (P = 0.01). Among these indications, patients with alcoholic cirrhosis had lost significantly more weight (P<0.01), and those with hepatitis C virus (P = 0.01) and autoimmune hepatitis (P = 0.02) had lost significantly less weight.

CONCLUSIONS

Patients experienced weight loss during liver disease independent of age, sex, schooling and income; however, the etiology of liver disease was related to weight loss.

[Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): liver failure and transplantation]

Patients with liver failure have a high prevalence of malnutrition, which is related to metabolic abnormalities due to the liver disease, reduced nutrient intake and alterations in digestive function, among other factors. In general, in patients with liver failure, metabolic and nutritional support should aim to provide adequate nutrient intake and, at the same time, to contribute to patients' recovery through control or reversal of metabolic alterations. In critically-ill patients with liver failure, current knowledge indicates that the organ failure is not the main factor to be considered when choosing the nutritional regimen. As in other critically-ill patients, the enteral route should be used whenever possible. The composition of the nutritional formula should be adapted to the patient's metabolic stress. Despite the physiopathological basis classically described by some authors who consider amino acid imbalance to be a triggering factor and key element in maintaining encephalopathy, there are insufficient data to recommend "specific" solutions (branched-chain amino acid-enriched with low aromatic amino acids) as part of nutritional support in patients with acute liver failure. In patients undergoing liver transplantation, nutrient intake should be started early in the postoperative period through transpyloric access. Prevention of the hepatic alterations associated with nutritional support should also be considered in distinct clinical scenarios.

Body composition and overweight of liver transplant recipients

BACKGROUND

Overweight is often used as a description after liver transplantation (LTx), but studies on body composition of patients submitted to LTx have only been devoted to early postoperative periods; there is little information regarding abdominal obesity after LTx. The aim of this study was to assess body composition, body mass index (BMI), and waist circumference and verify the prevalence and risk factors for excessive weight, obesity, and abdominal obesity in long-term survivors of LTx.

METHODS

Post-LTx patients with at least 1 year post-LTx were assessed for their body composition (by bioimpedance), BMI, and waist circumference. Demographic, socioeconomic, lifestyle, and clinical and dietetic variables were collected to assess risk factors using linear and logistic regression analyses.

RESULTS

We evaluated 143 patients (51±13 years; 59.4% male; median time since LTx: 4 years). The majority of patients had excessive weight, considering BMI, (58.1%). Considering body composition, 69.9% of patients were overweight and 37.8% obese. Some degree of abdominal obesity was seen in 88% of patients. Independent risk factors for overweight, obesity, and abdominal obesity after LTx included greater BMI before liver disease, weight gain since LTx, family history of overweight, smoking, working, being married, having less time since transplantation, a lower calcium intake, and less sleeping hours.

CONCLUSIONS

The majority of patients are overweight or obese after LTx, and many of the associated risk factors are modifiable. Thus, patients, especially those who already have identified risk factors for overweight and obesity, undergoing LTx should be encouraged to engage in lifestyle changes early.

Protective effect of probiotics on intestinal barrier function in malnourished rats after liver transplantation

BACKGROUND

Most patients waiting for liver transplantation have end-stage liver diseases with malnutrition, which is prone to induce intestinal barrier dysfunction after liver transplantation. We aimed to study the effect of probiotics on intestinal barrier function in malnourished rats following liver transplantation with long-term antibiotics.

METHODS

Twelve Lewis rats were selected as donors. Twelve BN rats, which served as recipients, were subjected to malnutrition by semi-starvation for 4-5 weeks. They were randomly divided into two groups: a control group which received phosphate-buffered saline and a probiotics group which received Bifidobacterium and Lactobacillus. All recipients were injected with intramuscular imipenem and subcutaneous cyclosporine A. Furthermore, six normal BN rats without any drugs or operations served as a normal group. Eight days after operation, all rats were sacrificed for examination of the following parameters: serum levels of endotoxin and TNF-alpha, bacterial translocation, intestinal microflora, ileocecal sIgA, lymphocyte numbers, and phenotypes (CD4, CD8, alphabetaTCR, gammadeltaTCR) of Peyer's patches.

RESULTS

In recipients subjected to malnutrition, weight decreased by 20% and they survived until 8 days after operation. Compared with the normal group, all recipients on postoperative day 8 showed increased levels of serum endotoxin and TNF-alpha as well as increased counts of translocated bacteria. Meanwhile, there were decreases in counts of Bifidobacterium and Lactobacillus in the ileocecum, sIgA concentration, and lymphocytes of Peyer's patches. Moreover, partial alteration in lymphocyte phenotypes was evidenced by elevated ratios of CD8+ and gammadeltaTCR+ lymphocytes. In contrast, compared to the control group, supplementation with probiotics reduced the levels of serum endotoxin, TNF-alpha and bacterial translocation, increased the counts of Bifidobacterium and Lactobacillus, the concentration of sIgA and lymphocytes of Peyer's patches, and also slightly restored the alteration of lymphocyte phenotypes.

CONCLUSION

Supplementation with probiotics including Bifidobac-terium and Lactobacillus promoted partial restoration of intestinal microflora and improved intestinal barrier function in malnourished rats after liver transplantation with long-term use of antibiotics.