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Tan JYT, Cheah CCM, Wang YT, Chang PEJ, Krishnamoorthy TL, Tan HK, Salazar E. Outpatient screening with the Royal Free Hospital-Nutrition Prioritizing Tool for patients with cirrhosis at risk of malnutrition. Nutrition 2023; 114:112139. [PMID: 37450959 DOI: 10.1016/j.nut.2023.112139] [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: 02/24/2023] [Revised: 06/13/2023] [Accepted: 06/17/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES Malnutrition is common among inpatients with cirrhosis. However, data on the prevalence of malnutrition among stable ambulatory patients with cirrhosis is lacking. We sought to investigate the prevalence of patents at risk of malnutrition (ARMN) among ambulatory patients with cirrhosis using the Royal Free Hospital-Nutrition Prioritizing Tool (RFH-NPT) and the Malnutrition Universal Screening Tool (MUST) and compare their correlation to clinical outcomes. METHODS Patients attending an outpatient liver cirrhosis clinic at a tertiary hospital were screened for ARMN using both the RFH-NPT and MUST (defined by a score of ≥2 for either tool). Differences in clinical outcomes after 6 mo were compared. RESULTS There were 134 patients recruited. The RFH-NPT identified more ARMN patients compared with MUST (32.8% versus 8.2%; P < 0.01; Cohen κ, 0.27 [95% CI, 0.12-0.42]; P < 0.001). Fluid overload at recruitment was the only independent predictor of disagreement between the RFH-NPT and MUST (odds ratio [OR], 43.14; 95% CI, 8.70-214.00; P < 0.001). There was a trend toward an increased risk of mortality for ARMN patients by the RFH-NPT (hazard ratio, 3.58; 95% CI, 0.81-15.83; P = 0.06) but not by the MUST (P = 0.62). The incidence of hospital admissions in ARMN patients was higher by the RFH-NPT, with an incidence rate ratio of 13.27 (95% CI, 5.11-43.70; P < 0.001), but not in ARMN patients by the MUST (P = 0.85). Being ARMN by the RFH-NPT was the only independent predictor of hospital admissions (OR, 15.08; 95% CI, 2.47-91.98; P = 0.003). CONCLUSIONS The RFH-NPT identified more ARMN patients when compared with the MUST, especially among patients with fluid overload. Patients at risk of malnutrition were at an increased risk of hospital admissions and possibly death.
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Affiliation(s)
- Jin Y T Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital
| | - Chang C M Cheah
- Department of Gastroenterology and Hepatology, Singapore General Hospital
| | - Yu T Wang
- Department of Gastroenterology and Hepatology, Singapore General Hospital
| | - Pik E J Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital
| | | | - Hiang K Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital
| | - Ennaliza Salazar
- Department of Gastroenterology and Hepatology, Singapore General Hospital.
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Portal Vein Embolization: Rationale, Techniques, and Outcomes to Maximize Remnant Liver Hypertrophy with a Focus on Contemporary Strategies. Life (Basel) 2023; 13:life13020279. [PMID: 36836638 PMCID: PMC9959051 DOI: 10.3390/life13020279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Hepatectomy remains the gold standard for curative therapy for patients with limited primary or metastatic hepatic tumors as it offers the best survival rates. In recent years, the indication for partial hepatectomy has evolved away from what will be removed from the patient to the volume and function of the future liver remnant (FLR), i.e., what will remain. With this regard, liver regeneration strategies have become paramount in transforming patients who previously had poor prognoses into ones who, after major hepatic resection with negative margins, have had their risk of post-hepatectomy liver failure minimized. Preoperative portal vein embolization (PVE) via the purposeful occlusion of select portal vein branches to promote contralateral hepatic lobar hypertrophy has become the accepted standard for liver regeneration. Advances in embolic materials, selection of treatment approaches, and PVE with hepatic venous deprivation or concurrent transcatheter arterial embolization/radioembolization are all active areas of research. To date, the optimal combination of embolic material to maximize FLR growth is not yet known. Knowledge of hepatic segmentation and portal venous anatomy is essential before performing PVE. In addition, the indications for PVE, the methods for assessing hepatic lobar hypertrophy, and the possible complications of PVE need to be fully understood before undertaking the procedure. The goal of this article is to discuss the rationale, indications, techniques, and outcomes of PVE before major hepatectomy.
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Malnutrition as a risk factor of adverse postoperative outcomes in patients undergoing hepatic resection: analysis of US hospitals. Br J Nutr 2022; 128:675-683. [PMID: 34551838 DOI: 10.1017/s0007114521003809] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patients with liver cancer or space-occupying cysts suffer from malnutrition due to compression of gastric and digestive structures, liver and cancer-mediated dysmetabolism, and impaired nutrient absorption. As proportion of these patients requires removal of lesions through hepatic resection, it is important to evaluate the effects of malnutrition on post-hepatectomy outcomes. In our study approach, 2011-2017 National Inpatient Sample was used to isolate in-hospital hepatectomy cases, which were stratified using malnutrition (composite of malnutrition, sarcopenia and weight loss/cachexia). The malnutrition-absent controls were matched to cases using nearest neighbour propensity score matching method and compared with the following endpoints: mortality, length of stay, hospitalisation costs and postoperative complications. There were 2531 patients in total who underwent hepatectomy with matched number of controls from the database; following the match, malnutrition cohort (compared with controls) was more likely to experience in-hospital death (6·60 % v. 5·25 % P < 0·049, OR 1·27, 95 % CI 1·01, 1·61) and was more likely to have higher length of stay (18·10 d v. 9·32 d, P < 0·001) and hospitalisation costs ($278 780 v. $150 812, P < 0·001). In terms of postoperative complications, malnutrition cohort was more likely to experience bleeding (6·52 % v. 3·87 %, P < 0·001, OR 1·73, 95 % CI 1·34, 2·24), infection (6·64 % v. 2·49 %, P < 0·001, OR 2·79, 95 % CI 2·07, 3·74), wound complications (4·5 % v. 1·38 %, P < 0·001, OR 3·36, 95 % CI 2·29, 4·93) and respiratory failure (9·40 % v. 4·11 %, P < 0·001, OR 2·42, 95 % CI 1·91, 3·07). In multivariate analysis, malnutrition was associated with higher mortality (P < 0·028, adjusted OR 1·3, 95 % CI 1·03, 1·65). Thus, we conclude that malnutrition is a risk factor of postoperative mortality in patients undergoing hepatectomy.
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Mohta S, Anand A, Sharma S, Qamar S, Agarwal S, Gunjan D, Singh N, Madhusudhan KS, Pandey RM, Saraya A. Randomised clinical trial: effect of adding branched chain amino acids to exercise and standard-of-care on muscle mass in cirrhotic patients with sarcopenia. Hepatol Int 2022; 16:680-690. [PMID: 35469091 PMCID: PMC9037580 DOI: 10.1007/s12072-022-10334-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 03/21/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The role of branched-chain amino acids (BCAA) in improving muscle mass in cirrhosis is presently debatable. AIMS To evaluate the role of BCAA in improving muscle mass in a double-blind randomized placebo-controlled trial in patients with cirrhosis having sarcopenia. METHODS Consecutive patients with cirrhosis with Child-Pugh score < 10 and sarcopenia were randomized to receive either 12 g/day of BCAA orally or a placebo (1:1) for 6 months in addition to a home-based exercise program (30 min/day), dietary counselling and standard medical therapy. Sarcopenia was defined according to gender-specific axial skeletal muscle index (SMI) cut-offs. The primary endpoint was a change in muscle mass based on CT scan (SMI) after 6 months of supplementation. RESULTS Sixty patients [mean age 41.6 ± 9.9 years; males (66.6%) of predominantly viral (40%) and alcohol-related (31.7%) cirrhosis] were randomized. Baseline clinical and demographic characters were similar except MELD score (10.2 ± 2.8 vs. 12.2 ± 3.5, p = 0.02) and calorie intake (1838.1 kcal ± 631.5 vs. 2217.5 kcal ± 707.3, p = 0.03), both being higher in the placebo arm. After adjusting for both baseline confounders, baseline SMI and protein intake, the change in SMI at 6 months was similar in both groups [mean adjusted difference (MAD) + 0.84, CI - 2.9; + 1.2, p = 0.42] by intention-to-treat analysis. The secondary outcomes including change in handgrip strength (p = 0.65), 6-m gait speed (p = 0.20), 6-min walk distance (p = 0.39) were similar in both arms. Four patients had minor adverse events in each arm. CONCLUSION Addition of BCAA to exercise, dietary counselling and standard medical therapy did not improve muscle mass in patients with cirrhosis having sarcopenia. (CTRI/2019/05/019269). TRIAL REGISTRATION NUMBER CTRI/2019/05/019269 (Clinical Trials Registry of India).
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Affiliation(s)
- Srikant Mohta
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Abhinav Anand
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Sanchit Sharma
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Sumaira Qamar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Samagra Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Namrata Singh
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029 India
| | | | - Ravindra Mohan Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110029 India
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Kim J, Randhawa H, Sands D, Lambe S, Puglia M, Serrano PE, Pinthus JH. Muscle-Invasive Bladder Cancer in Patients with Liver Cirrhosis: A Review of Pertinent Considerations. Bladder Cancer 2021. [DOI: 10.3233/blc-211536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The incidence of liver cirrhosis is increasing worldwide. Patients with cirrhosis are generally at a higher risk of harbouring hepatic and non-hepatic malignancies, including bladder cancer, likely due to the presence of related risk factors such as smoking. Cirrhosis can complicate both the operative and non-surgical management of bladder cancer. For example, cirrhotic patients undergoing abdominal surgery generally demonstrate worse postoperative outcomes, and chemotherapy in patients with cirrhosis often requires dose reduction due to its direct hepatotoxic effects and reduced hepatic clearance. Multiple other considerations in the peri-operative management for cirrhosis patients with muscle-invasive bladder cancer must be taken into account to optimize outcomes in these patients. Unfortunately, the current literature specifically related to the treatment of cirrhotic bladder cancer patients remains sparse. We aim to review the literature on treatment considerations for this patient population with respect to perioperative, surgical, and adjuvant management.
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Affiliation(s)
- John Kim
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - David Sands
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Shahid Lambe
- Division of Urology, McMaster University, Hamilton, ON, Canada
- McMaster Institute of Urology, St. Joseph’s Hospital, Hamilton, ON, Canada
| | - Marco Puglia
- Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
| | | | - Jehonathan H. Pinthus
- Division of Urology, McMaster University, Hamilton, ON, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
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Lee DU, Fan GH, Ahern RR, Karagozian R. The effect of malnutrition on the infectious outcomes of hospitalized patients with cirrhosis: analysis of the 2011-2017 hospital data. Eur J Gastroenterol Hepatol 2021; 32:269-278. [PMID: 33252419 DOI: 10.1097/meg.0000000000001991] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In patients with cirrhosis, there is a clinical concern that the development of protein-calorie malnutrition will affect the immune system and predispose these patients to increased infectious outcomes. AIMS In this study, we evaluate the effects of malnutrition on the infectious outcomes of patients admitted with cirrhosis. MATERIALS AND METHODS This study used the 2011-2017 National Inpatient Sample to identify patients with cirrhosis. These patients were stratified using malnutrition (protein-calorie malnutrition, cachexia, and sarcopenia) and matched using age, gender, and race with 1:1 nearest neighbor matching method. The endpoints included mortality and infectious outcomes. RESULTS After matching, there were 96 842 malnutrition-present cohort and equal number of controls. In univariate analysis, the malnutrition cohort had higher hospital mortality [10.40 vs. 5.04% P < 0.01, odds ratio (OR) 2.18, 95% confidence interval (CI) 2.11-2.26]. In multivariate models, malnutrition was associated with increased mortality [P < 0.01, adjusted odds ratio (aOR) 1.32, 95% CI 1.27-1.37] and infectious outcomes, including sepsis (P < 0.01, aOR 1.94, 95% CI 1.89-2.00), pneumonia (P < 0.01, aOR 1.68, 95% CI 1.63-1.73), UTI (P < 0.01, aOR 1.39, 95% CI 1.35-1.43), cellulitis (P < 0.01, aOR 1.09, 95% CI 1.05-1.13), cholangitis (P < 0.01, aOR 1.39, 95% CI 1.26-1.55), and clostridium difficile (P < 0.01, aOR 2.11, 95% CI 1.92-2.31). CONCLUSION The results of this study indicate that malnutrition is an independent risk factor of hospital mortality and local/systemic infections in patients admitted with cirrhosis.
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Affiliation(s)
- David Uihwan Lee
- Division of Gastroenterology, Liver Center, Tufts Medical Center, 800 Washington Street, Boston, Massachusetts, USA
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Watanabe M, Tuccinardi D, Ernesti I, Basciani S, Mariani S, Genco A, Manfrini S, Lubrano C, Gnessi L. Scientific evidence underlying contraindications to the ketogenic diet: An update. Obes Rev 2020; 21:e13053. [PMID: 32648647 PMCID: PMC7539910 DOI: 10.1111/obr.13053] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/31/2022]
Abstract
First identified as a feasible treatment for intractable epilepsy, the ketogenic diet (KD) has recently gained popularity thanks to growing evidence on applications such as weight loss, most importantly, but also NAFLD, cancer, neurologic conditions and chronic pain. As with any treatment, whether pharmacologic or not, the KD might not be an appropriate intervention for every individual, and a number of contraindications have been proposed, now deeply rooted into clinical practice, excluding de facto many patients that could benefit from its use. However, many of these concerns were expressed due to the absence of clinical studies conducted on fragile populations, and an assessment of lately emerged evidence relative to KD safety is currently lacking and much needed. We herein provide a critical revision of the literature behind each safety alert, in order to guide through the treatment options in the case of subjects with an indication to the KD and a borderline safe situation. Based on available evidence, the possible use of this diet as a therapeutic intervention should be assessed on a patient-to-patient basis by adequately skilled medical doctors, keeping in mind current recommendations, but reading them through the knowledge of the current state of the art.
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Affiliation(s)
- Mikiko Watanabe
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - Dario Tuccinardi
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Ilaria Ernesti
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy.,Department of Surgical Sciences, Surgical Endoscopy Unit, Sapienza University of Rome, Rome, Italy
| | - Sabrina Basciani
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - Stefania Mariani
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - Alfredo Genco
- Department of Surgical Sciences, Surgical Endoscopy Unit, Sapienza University of Rome, Rome, Italy
| | - Silvia Manfrini
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Carla Lubrano
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - Lucio Gnessi
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
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Kamran U, Towey J, Khanna A, Chauhan A, Rajoriya N, Holt A. Nutrition in alcohol-related liver disease: Physiopathology and management. World J Gastroenterol 2020; 26:2916-2930. [PMID: 32587439 PMCID: PMC7304106 DOI: 10.3748/wjg.v26.i22.2916] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/08/2020] [Accepted: 05/21/2020] [Indexed: 02/06/2023] Open
Abstract
Malnutrition encompassing both macro- and micro-nutrient deficiency, remains one of the most frequent complications of alcohol-related liver disease (ArLD). Protein-energy malnutrition can cause significant complications including sarcopenia, frailty and immunodepression in cirrhotic patients. Malnutrition reduces patient’s survival and negatively affects the quality of life of individuals with ArLD. Moreover, nutritional deficit increases the likelihood of hepatic decompensation in cirrhosis. Prompt recognition of at-risk individuals, early diagnosis and treatment of malnutrition remains a key component of ArLD management. In this review, we describe the pathophysiology of malnutrition in ArLD, review the screening tools available for nutritional assessment and discuss nutritional management strategies relevant to the different stages of ArLD, ranging from acute alcoholic hepatitis through to decompensated end stage liver disease.
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Affiliation(s)
- Umair Kamran
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, United Kingdom
| | - Jennifer Towey
- Department of Dietetics, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, United Kingdom
| | - Amardeep Khanna
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, United Kingdom
| | - Abhishek Chauhan
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, United Kingdom
- Centre for Liver Research, Institute of Immunology and Inflammation, and National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, The Medical School, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, United Kingdom
| | - Andrew Holt
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, United Kingdom
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Abou-Hashem RM, Shaat MM, Hamza SA, Mahmoud NH, Ali SM. The Relationship between Trace Elements and Depression among Older Patients with Chronic Liver Disease. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2020. [DOI: 10.29333/ejgm/7887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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10
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Skladany L, Vnencakova J, Laffers L, Skvarkova B, Hrubá E, Molcan P, Koller T. Adherence to Oral Nutritional Supplements After Being Discharged from the Hospital is Low but Improves Outcome in Patients with Advanced Chronic Liver Disease. Patient Prefer Adherence 2020; 14:2559-2572. [PMID: 33447017 PMCID: PMC7802017 DOI: 10.2147/ppa.s283034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/20/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Patients with advanced chronic liver disease (ACLD) often have a poor nutritional status. In the management, current guidelines recommend dietary counseling and oral nutritional supplements (ONS). Nutritional goals and adherence to ONS are difficult to achieve while studies addressing adherence are scarce. We aimed to evaluate adherence to ONS, the associated factors, and its impact on outcome among ALCD patients who are discharged from the hospital. PATIENTS AND METHODS We identified consecutive hospitalized patients with ACLD from the cirrhosis registry and ONS prescription at discharge. Baseline demographics, anthropometrics, hand-grip strength (HGS), nutritional, and laboratory parameters were recorded. Adherence was assessed at 30, 90, and 180 days, but not in patients who did not survive or in those who underwent liver transplantation (LT) before the time-point. RESULTS From the registry containing 1004 patients, we included 450 cases, the median age was 56.3 (IQR 47-62), 60% were males, 63.8% had alcoholic etiology, and the median model for end-stage liver disease score (MELD) was 16 (11-21). During follow-up, 13.6%, 23.6%, and 31.1% of patients have died within 30, 90, and 180 days, respectively, and 21 underwent LT. Adherence to ONS in surviving patients was observed in 46%, 26.1%, and 16.9% within 30, 90, and 180 days, respectively. Baseline refractory ascites (HR=0.43, 0.24-0.76), HGS (HR=1.03, 1.01-1.06), and mid-arm circumference (HR=0.93, 0.88-0.99) were independently associated with 30-day adherence. Among patients who survived beyond 30 days, adherents for >30 days had improved synthetic liver function, HGS, a higher probability of LT (HR=1.7, 1.03-2.8) and lower risk of death (HR=0.65, 0.45-0.89), particularly those with MELD>16 (OR=0.55, 0.36-0.85) and low HGS (OR=0.61, 0.39-0.93). CONCLUSION In ACLD patients after discharge, adherence to ONS steeply declined and was associated with baseline refractory ascites and low muscle strength. Adherence to ONS also improved liver function, muscle strength, and survival.
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Affiliation(s)
- Lubomir Skladany
- Hepatology, Gastroenterology and Transplantation (HEGITO) Department of the 2nd Department of Medicine, Slovak Medical University, FD Roosevelt Hospital, Banska Bystrica, Slovakia
| | - Jana Vnencakova
- Hepatology, Gastroenterology and Transplantation (HEGITO) Department of the 2nd Department of Medicine, Slovak Medical University, FD Roosevelt Hospital, Banska Bystrica, Slovakia
| | - Lukas Laffers
- Department of Mathematics, Faculty of Natural Sciences, Matej Bel University, Banska Bystrica, Slovakia
| | - Beata Skvarkova
- Hepatology, Gastroenterology and Transplantation (HEGITO) Department of the 2nd Department of Medicine, Slovak Medical University, FD Roosevelt Hospital, Banska Bystrica, Slovakia
| | - Eva Hrubá
- Hepatology, Gastroenterology and Transplantation (HEGITO) Department of the 2nd Department of Medicine, Slovak Medical University, FD Roosevelt Hospital, Banska Bystrica, Slovakia
| | - Pavol Molcan
- Hepatology, Gastroenterology and Transplantation (HEGITO) Department of the 2nd Department of Medicine, Slovak Medical University, FD Roosevelt Hospital, Banska Bystrica, Slovakia
| | - Tomas Koller
- Gastroenterology and Hepatology Subdiv. of the 5th Department of Medicine, Comenius University Faculty of Medicine, University Hospital Bratislava, Bratislava, Slovakia
- Correspondence: Tomas Koller Gastroenterology and Hepatology Subdiv. of the 5th Department of Medicine, Comenius University Faculty of Medicine, University Hospital Bratislava, Ruzinovska 6, Bratislava82606, SlovakiaTel +42190518692 Email
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11
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Fallahzadeh MA, Rahimi RS. Hepatic Encephalopathy and Nutrition Influences: A Narrative Review. Nutr Clin Pract 2019; 35:36-48. [PMID: 31872484 DOI: 10.1002/ncp.10458] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Hepatic encephalopathy (HE) is a potentially reversible neurocognitive condition seen in patients with advanced liver disease. The overt form of HE has been reported in up to 45% of patients with cirrhosis. This debilitating condition is associated with increased morbidity and mortality and imposes a significant burden on the caregivers and healthcare system. After providing an overview of HE epidemiology and pathophysiology, this review focuses on the interaction of HE and frailty, nutrition requirements and recommendations in cirrhotic patients with HE, and current dietary and pharmacologic options for HE treatment.
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Affiliation(s)
- Mohammad Amin Fallahzadeh
- Division of Hepatology, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Robert S Rahimi
- Division of Hepatology, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
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12
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Lamarti E, Hickson M. The contribution of ascitic fluid to body weight in patients with liver cirrhosis, and its estimation using girth: a cross-sectional observational study. J Hum Nutr Diet 2019; 33:404-413. [PMID: 31775184 DOI: 10.1111/jhn.12721] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND There is a high prevalence of malnutrition among people with decompensated liver disease. Standard nutritional screening tools use weight and body mass index (BMI) to identify risk, although these are difficult to measure for those with ascites, often secondary to liver cirrhosis. Dietetic guidance suggests adjusting for ascitic weight by 2.2-14 kg, although there is a lack of evidence to substantiate these values. The present study aimed to measure the contribution of ascitic fluid weight and compare this with the current guidance, as well as to examine whether girth circumference can be used to estimate ascitic weight. METHODS A cross-sectional, observational study was conducted over 13 weeks. Participants attending for paracentesis were weighed, their girths measured, and BMI was calculated pre- and post-paracentesis. Fluid removed via paracentesis was recorded. Ethical approval was received (IRAS project ID: 218747). RESULTS Eighteen participants underwent paracentesis. The range of ascitic fluid drained was 3.8-19 L [mean (SD) = 8.7 (3.7) L]. Weight difference between pre- and post-paracentesis was in the range 4.5-20 kg [mean (SD) = 8.7 (3.9) kg]. Ascitic fluid weight is shown to be higher in each category (minimal, moderate, severe ascites) than the current guidance values. Weight difference was greater than 14 kg in 11% (n = 2) of participants. A strong, statistically significant relationship (rho = 0.68, P ≤ 0.01) between ascitic weight and pre-paracentesis girth was found. An equation was formulated to enable the estimation of ascitic fluid from pre-paracentesis girth. CONCLUSIONS Current dietetic guidance should be re-evaluated to reflect the greater weight differences identified. Measuring girth pre-paracentesis may help to inform dry weight estimation. Further research is required to verify the accuracy of estimating ascitic weight from pre-paracentesis girth.
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Affiliation(s)
- E Lamarti
- Therapy Department, Royal Cornwall Hospitals NHS Trust, Truro, UK.,Institute of Health and Community, University of Plymouth, Plymouth, UK
| | - M Hickson
- Institute of Health and Community, University of Plymouth, Plymouth, UK
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Nartey YA, Asem M, Agyei-Nkansah A, Awuku YA, Setorglo J, Duah A, Bampoh S, Ayawin J, Asibey SO, Ye W, Afihene MY, Roberts L, Plymoth A. Nutritional management of cirrhosis patients: A qualitative study exploring perceptions of patients and health workers in Ghana. Clin Nutr ESPEN 2019; 34:18-22. [PMID: 31677706 DOI: 10.1016/j.clnesp.2019.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/30/2019] [Accepted: 09/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Malnutrition is common among patients with end stage liver disease including liver cirrhosis and liver cancer. Optimal nutrition is important to reduce morbidity and mortality of these patients. There is limited qualitative data on nutritional status and management of chronic liver disease patients. We aimed to explore the knowledge, opinions and practices of cirrhosis patients and health workers in nutritional management of cirrhosis in Ghana, in order to determine whether there is a need to improve nutritional care for cirrhosis patients. METHODS We conducted a qualitative study using semi-structured interviews of cirrhotic patients (n = 16) and healthcare providers (n = 27) in three academic centers in Accra, Kumasi and Cape Coast (Ghana). Recruitment was by purposive sampling of patients attending specialist liver disease clinics. The recorded data were analyzed using NVivo 11 software, with generation of codes, themes and subthemes. RESULTS The major themes that emerged from the data included nutrition as part of care delivery during the hospital visit, nutritional recommendations, dietary changes and long-term practice improvement. The results showed that patients and health workers felt dietary recommendations for patients were frequently addressed, but could be significantly improved. We found that in the opinion of study participants, local guidelines are important and necessary in nutritional management of cirrhosis patients, and that participants felt it was difficult to change dietary habits following cirrhosis diagnosis. CONCLUSIONS These results suggest that nutritional management of cirrhosis patients in Ghana requires improvement. Strategies to improve this could include a multi-disciplinary approach to nutritional management, development of local guidelines and continued nutritional assessment, monitoring and follow-up.
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Affiliation(s)
- Yvonne Ayerki Nartey
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Internal Medicine, School of Medical Sciences University of Cape Coast, Cape Coast, Ghana.
| | - Mawuena Asem
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Yaw Asante Awuku
- Department of Internal Medicine, School of Medical Sciences University of Cape Coast, Cape Coast, Ghana
| | - Jacob Setorglo
- Department of Clinical Nutrition and Dietetics, School of Medical Sciences University of Cape Coast, Cape Coast, Ghana
| | - Amoako Duah
- Department of Medicine, Korle Bu Teaching Hospital, Accra, Ghana
| | - Sally Bampoh
- Department of Medicine, Korle Bu Teaching Hospital, Accra, Ghana
| | - Joshua Ayawin
- Department of Medicine, Komfo-Anokye Teaching Hospital, Kumasi, Ghana
| | | | - Weimin Ye
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | | | - Lewis Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Minnesota, USA
| | - Amelie Plymoth
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Avelino DD, Maltos AL, Portari GV, Gonçalves ÁDC, da Cunha DF. Vitamin C Status in Hospitalized Adults According to Subjective Global Assessment Method. JPEN J Parenter Enteral Nutr 2018; 43:789-793. [PMID: 30350314 DOI: 10.1002/jpen.1460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 09/18/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND The subjective global assessment (SGA) is a powerful tool for nutrition status assessment. Our aim was to compare vitamin C serum levels among patients classified as A, B, or C in the SGA. METHODS One hundred-and-fifty adults in the wards of the University Hospital participated in this study. Besides SGA, all cases were submitted to anthropometry, bioelectrical impedance analysis (BIA), and 24-hour dietary recall. Laboratory data included blood hemoglobin, serum ferritin, serum albumin, transferrin, C-reactive protein (CRP), and vitamin C. Acute phase response was defined by serum CRP > 0.5 mg/dL; low serum vitamin C was defined by serum levels < 0.4 mg/dL. Analysis of variance and χ2 tests were used to compare groups; P < 0.05 was considered significant. RESULTS Patients were diagnosed as SGA A (n = 76), B (n = 38), or C (n = 36) and showed different anthropometry and BIA. The same occurred, respectively, with vitamin C (median; range, in mg/day) intake (55.0; 4.7-140.6 vs 34.0; 10.3-244.2 vs 15.8; 2.3-124.0) and high (%) CRP (88.3 vs 65.8 vs 48.7) and low (%) vitamin C serum levels (21.1 vs 34.2 vs 63.9). CONCLUSION Patients with worst nutrition parameters (SGA C) showed lower ascorbic acid serum levels than those classified as SGA A or B. These results are in accordance with reduced vitamin C intake and the presence of acute phase response.
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Affiliation(s)
- Dewelyn Dias Avelino
- Postgraduate Program in Health Sciences, Federal University of Triângulo Mineiro, Uberaba/MG, Brazil
| | - André Luiz Maltos
- Clinical Pathology Unit, Federal University of Triângulo Mineiro, Uberaba/MG, Brazil
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15
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Vasco M, Paolillo R, Schiano C, Sommese L, Cuomo O, Napoli C. Compromised nutritional status in patients with end-stage liver disease: Role of gut microbiota. Hepatobiliary Pancreat Dis Int 2018; 17:290-300. [PMID: 30173786 DOI: 10.1016/j.hbpd.2018.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with end-stage liver disease (ESLD) have a compromised nutritional status because of the liver crucial role in regulating metabolic homeostasis and energy balance. DATA SOURCES A systematic review of literature based on extensive relevant articles published from 2001 to 2017 in English in PubMed database was performed by searching keywords such as liver disease, non-alcoholic liver disease, alcoholic liver disease, malnutrition, epigenetics, gut microbiota, and probiotics. RESULTS Liver transplantation would be one eligible therapy for ESLD patients, even if, the clinical outcome is negatively influenced by malnutrition and/or infections. The malnutrition is a condition of nutrient imbalance with a high incidence in ESLD patients. An accurate evaluation of nutritional status could be fundamental for reducing complications and prolonging the survival of ESLD patients including those undergoing liver transplantation. In addition, the interaction among nutrients, diet and genes via epigenetics has emerged as a potential target to reduce the morbidity and mortality in ESLD patients. The malnutrition induces changes in gut microbiota causing dysbiosis with a probable translocation of bacteria and/or pathogen-derived factors from the intestine to the liver. Gut microbiota contribute to the progression of chronic liver diseases as well as hepatocellular carcinoma. The administration of probiotics modulating gut microbiota could improve all chronic liver diseases. CONCLUSIONS This review provides an update on malnutrition status linked to epigenetics and the potential benefit of some probiotics on the management of ESLD patients. In support of this view and to reveal the constant and growing interest in this field, some clinical trials are reported.
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Affiliation(s)
- Maria Vasco
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Regional Reference Laboratory of Transplant Immunology, Department of Internal and Specialty Medicine, Azienda Ospedaliera Universitaria, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy
| | - Rossella Paolillo
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Regional Reference Laboratory of Transplant Immunology, Department of Internal and Specialty Medicine, Azienda Ospedaliera Universitaria, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy
| | | | - Linda Sommese
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Regional Reference Laboratory of Transplant Immunology, Department of Internal and Specialty Medicine, Azienda Ospedaliera Universitaria, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy; Department of Experimental Medicine, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy.
| | - Oreste Cuomo
- Department of Liver Transplant, AORN A. Cardarelli, Naples, Italy
| | - Claudio Napoli
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Regional Reference Laboratory of Transplant Immunology, Department of Internal and Specialty Medicine, Azienda Ospedaliera Universitaria, Università degli Studi della Campania "Luigi Vanvitelli", Naples 80138, Italy; IRCCS SDN, Naples, Italy; Department of Medical, Surgical, Neurological, Metabolic and Geriatric Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
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16
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Shuja A, Malespin M, Scolapio J. Nutritional Considerations in Liver Disease. Gastroenterol Clin North Am 2018; 47:243-252. [PMID: 29413017 DOI: 10.1016/j.gtc.2017.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Malnutrition occurs in most patients with advanced liver diseases and is associated with higher rates of morbidity and mortality. In this article, the authors discuss the pathophysiology of malnutrition and methods to optimize nutrition status in liver disease and include a brief section on perioperative and postoperative nutrition.
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Affiliation(s)
- Asim Shuja
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, 4555 Emerson Street, Suite 300, Jacksonville, FL 32207, USA.
| | - Miguel Malespin
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, 4555 Emerson Street, Suite 300, Jacksonville, FL 32207, USA
| | - James Scolapio
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, 4555 Emerson Street, Suite 300, Jacksonville, FL 32207, USA
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17
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Nishikawa T, Asai A, Okamoto N, Yasuoka H, Nakamura K, Yokohama K, Ohama H, Tsuchimoto Y, Fukunishi S, Tsuda Y, Yamamoto K, Higuchi K. The preventive effect of the impaired liver function for antiemetic therapy against chemotherapy-induced nausea and vomiting in hepatocellular carcinoma patients. J Clin Biochem Nutr 2017; 61:222-227. [PMID: 29203965 PMCID: PMC5703785 DOI: 10.3164/jcbn.17-57] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 07/11/2017] [Indexed: 11/22/2022] Open
Abstract
Transarterial chemoembolization and hepatic arterial infusion chemotherapy are recommended for the treatment in patients with intermediate stage of hepatocellular carcinoma. Impaired liver function was sometime observed in patients with hepatocellular carcinoma after transarterial chemoembolization or hepatic arterial infusion chemotherapy. However, what kinds of factors deeply influence in impaired liver function are not clear. A retrospective study was performed to evaluate the risk factors of impaired liver function in cisplatin-naïve patients treated with these therapies using cisplatin. Prior to and 2 months after these therapies, we analyzed the liver function by Child-Pugh score in these patients. For assessing the severity of chemotherapy-induced nausea and vomiting, we utilized the Common Terminology Criteria for Adverse Events ver. 4.0. In hepatocellular carcinoma patients received these therapies using cisplatin, the cancer stage and treatment without neurokinin-1 (NK1) antagonist were found to be independent risk factors of the impaired liver function. The treatment with NK1 antagonist was effective in reducing chemotherapy-induced nausea and vomiting and patients treated with NK1 antagonist kept their liver functions after cisplatin-used these therapies. The treatment with NK1 antagonist was effective in chemotherapy-induced nausea and vomiting and prevented the impaired liver function associated with cisplatin-used these therapies in hepatocellular carcinoma patients.
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Affiliation(s)
- Tomohiro Nishikawa
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Akira Asai
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan.,Medical Laboratory, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Norio Okamoto
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Hidetaka Yasuoka
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Ken Nakamura
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Keisuke Yokohama
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Hideko Ohama
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Yusuke Tsuchimoto
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Shinya Fukunishi
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Yasuhiro Tsuda
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan.,Faculty of Nursing, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Kazuhiro Yamamoto
- Faculty of Radiology, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Kazuhide Higuchi
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan
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18
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Carpenter A, Pencharz P, Mouzaki M. Accurate estimation of energy requirements of young patients. J Pediatr Gastroenterol Nutr 2015; 60:4-10. [PMID: 25238120 DOI: 10.1097/mpg.0000000000000572] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The provision of optimal nutritional care is based on accurate estimations of patients' resting energy expenditure. The latter can be calculated with the use of predictive equations or measured with indirect calorimetry (IC). Owing to their ease of use, mathematical equations have largely replaced IC in clinical practice. This article examines the limitations and predictive inaccuracy of commonly used equations in pediatrics, which may contribute to the provision of poor nutritional care and directly affect patient outcomes. In addition, the role of IC is discussed and the physiology of nutrient metabolism, in terms of energy expenditure, is reviewed.
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Affiliation(s)
- Andrea Carpenter
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Canada
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