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

Neuropsychiatric sequelae after liver transplantation and their possible mechanism via the microbiota-gut-liver-brain axis

Patients after liver transplantation are often impacted by mental and even neuropsychiatric disorders, including depression, sleep disorders, anxiety, and post-traumatic stress disorder. Neuropsychiatric sequelae have an adverse impact on rehabilitation and can even incapacitate people, reducing their quality of life. Despite screening tools and effective treatments, neuropsychiatric sequelae after liver transplantation (NSALT) have not been fully diagnosed and treated. Current research suggests that NSALT may be partly related to intestinal microbial variation, but the detailed mechanism remains unclear. In this review, we describe the clinical and diagnostic features, prevalence, prediction, clinical course and outcome, management, and treatment of NSALT; we also summarize their mechanisms through the microbiota-gut-liver-brain axis. Finally, we propose to improve NSALT on the basis of adjusting the gastrointestinal flora, immune inflammation or vagus nerve (VN), providing a novel strategy for clinical prevention and treatment.

Anthropometric, biochemical and clinical assessment of malnutrition among Egyptian children with chronic liver diseases: a single institutional cross-sectional study

BACKGROUND

Malnutrition is a common problem among children with chronic liver diseases (CLD). We aimed to assess the nutritional status of children with CLD and to correlate the anthropometric indices with the severity of liver disease, liver function tests, insulin growth factor-1 (IGF-1) and 25-hydroxy vitamin D (25- OH D).

METHODS

A total of 69 patients with CLD and 50 healthy controls (6 months - 6 years) were included in the study. Nutritional status was assessed by anthropometric indices expressed in standard deviation score (Z score), biochemical, hematological and clinical parameters.

RESULTS

We found 52.2% of CLD patients underweight by weight for age (W/A); 50.2% were stunted by height for age/ length for age (HAZ or LAZ); and 39% exhibited wasting by weight/height or (length) for age (W/HZ or W/LZ) z scores analysis. The mean values of z scores for all anthropometric parameters were significantly correlated with unconjugated and conjugated bilirubin and INR (p < 0.05), except HAZ or LAZ. Also, a significant correlation to albumin was found, except for W/HZ or (W/LZ) (p = 0.157). The z scores < - 2 SD based on W/ H versus arm indicators showed significant differences in MUAC, UAA and AMA (p < 0.001). We found no correlation between anthropometric z-scores and the mean IGF-1 and (25- OH D) values (p > 0.05). Malnutrition was directly correlated with the severity of hepatic dysfunction, particularly, Child-Pugh C cases. The mean IGF-1 and (25- OH D) values were significantly correlated with the severity of liver disease (p < 0.001).

CONCLUSIONS

Our results identified anthropometric arm indicators and MUAC/A measurements as an effective applied methods for assessing nutritional status in CLD children. Moreover, Integrating comprehensive clinical assessment, anthropometric measurements and objective biochemical analyses is essential for evaluation, follow-up and management of CLD children with variable degree of malnutrition.

Factores relacionados con la calidad de vida de pacientes trasplantados

Introducción: El transplante es un procedimiento quirúrgico que constituye una forma de tratamiento eficaz para enfermedades en fase terminal. La realización del mismo puede generar mejoras en la calidad de vida de los individuos, así como en distintos factores que pueden interferir en esa percepción. El objetivo del presente estudio fue evaluar la influencia de factores socioeconómicos e inherentes al transplante en la percepción de la calidad de vida en pacientes que hayan sido sometidos a trasplantes de órganos. Materiales y Métodos: Estudio descriptivo, cuantitativo e de tipo transversal, realizado a través de un cuestionario socioeconómico y un cuestionario de calidad de vida, el World Health Organization Quality of Life- Bref. La muestra estuvo constituida por 258 participantes. Se realizaron las pruebas U de Mann Whitney y Kruskal Wallis, además de la correlación de Spearman. El nivel de significación adoptado fue p<0,05. Resultados: En los resultados se demuestra que recibir ingresos por encima de 2 salarios marcó una diferencia significativa con respecto a los participantes que reciben menores ingresos. Los casados presentaron una diferencia significativa en el área psicológica en comparación con los de otras situaciones conyugales. El trasplantado de hígado presentó diferencia significativa en la autoevaluación con respecto a los otros trasplantados. Discusión: El transplante, a pesar de no proporcionar una cura definitiva, rehabilita a los pacientes, lo que les posibilita que sientan placeres que habían sido olvidados debido a la enfermedad y que, poco a poco, hayan podido recuperarlos. Conclusiones: Los pacientes percibieron la calidad de vida de forma satisfactoria cuando recibían ingresos elevados, habían sido sometidos a transplante hepático y tenían pareja, esto impactó de manera positiva en esta percepción. Como citar este artigo: Leite AMC, Sousa PSA, Costa JR, Melo RA, Carvalho FO, Moura JC. Fatores relacionados à qualidade de vida de pacientes transplantados. Rev Cuid. 2019; 10(2): e715. http://dx.doi.org/10.15649/cuidarte.v10i2.715  

Preoperative nutrition and postoperative liver function: a correlation study of pediatric living donor liver transplantation

Objective

There is little information focusing on the nutritional issue of pediatric recipients before they receive living donor liver transplantation. This study illustrates the relationship between nutritional status and graft liver function and provides a reference regarding nutritional interventions in future studies.

Methods

We prospectively collected data from 30 pediatric living donor liver transplant recipients from January 1, 2016, to June 30, 2016. The information included demographic data, preoperative nutritional assessment, and postoperative laboratory examinations. The nutritional assessment included the serum concentration of vitamin D, bone density, trace element, and weight Z value. The laboratory examinations included white blood cell count, neutrophil percentage, hemoglobin, blood platelet, total protein, albumin, total bilirubin, direct bilirubin, alanine transaminase, aspartate aminotransferase (AST), alkaline phosphatase, gamma-glutamyl transpeptidase, creatinine, bile acid, blood glucose (Glu), prothrombin time, international normalized ratio, tacrolimus concentration, and graft-to-recipient weight ratio (GRWR). The data were collected on Days 1, 2, 3, 4, 5, 6, 7, 14, 30, and 60 after liver transplantation.

Results

The recipients consisted of 15 (50%) males and 15 (50%) females. The median age was 7 months (4–48 months). The mean height and weight were 69.07±9.98 cm and 8.09±2.63 kg, respectively. According to the univariate analysis, the gender, diagnosis, blood type, and GRWR did not significantly impact the liver function after the operation. The posttransplantation AST levels and Glu showed significant differences in terms of the nutritional status, with P<0.05. The multivariate correlation analysis showed that the serum concentrations of vitamin D and AST were midrange positively correlated, with P<0.05.

Conclusions

The nutritional status of patients with biliary atresia is relatively poor. There is a definite midrange positive correlation between nutrition and graft liver function that might play a relatively important role in the recovery of the graft.

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.

Background and design of the symptom burden in end-stage liver disease patient-caregiver dyad study

Over half a million Americans are affected by cirrhosis, the cause of end-stage liver disease (ESLD). Little is known about how symptom burden changes over time in adults with ESLD and their informal caregivers, which limits our ability to develop palliative care interventions that can optimize symptom management and quality of life in different patient-caregiver dyads. The purpose of this article is to describe the background and design of a prospective, longitudinal descriptive study, "Symptom Burden in End-Stage Liver Disease Patient-Caregiver Dyads," which is currently in progress. The study is designed to (i) identify trajectories of change in physical and psychological symptom burden in adults with ESLD; (ii) identify trajectories of change in physical and psychological symptom burden in caregivers of adults with ESLD; and (iii) determine predictors of types of patient-caregiver dyads that would benefit from tailored palliative care interventions. We aim for a final sample of 200 patients and 200 caregivers who will be followed over 12 months. Integrated multilevel and latent growth mixture modeling will be used to identify trajectories of change in symptom burden, linking those changes to clinical events, and quality of life outcomes and characterizing types of patient-caregiver dyads based on patient-, caregiver-, and dyad-level factors. Challenges we have encountered include unexpected attrition of study participants, participants not returning their baseline questionnaires, and hiring and training of research staff. The study will lay the foundation for future research and innovation in ESLD, end-of-life and palliative care, and caregiving.

A Comprehensive Review of Bioelectrical Impedance Analysis and Other Methods in the Assessment of Nutritional Status in Patients with Liver Cirrhosis

It is assumed that approximately 24–66% of patients with liver cirrhosis develop malnutrition. Numerous pathological processes lead to serious disorders of nutritional status in this group of patients. Malnutrition in the course of liver cirrhosis is associated with increased morbidity, complications, and low quality of life. Under these conditions, detection of malnutrition is of crucial importance. This review explores the complex mechanisms that lead to malnutrition in the course of liver cirrhosis and focuses on methods used in the assessment of nutritional status in cirrhotic patients. Among others, the role of bioelectrical impedance is highlighted. This noninvasive tool is promising and quite an accurate method of estimating body composition.

Concordance among methods of nutritional assessment in patients included on the waiting list for liver transplantation

BACKGROUND

The aim of the present study was to determine the extent of malnutrition in patients waiting for a liver transplant. The agreement among the methods of nutritional assessment and their diagnostic validity were evaluated.

METHODS

Patients on the waiting list for liver transplantation (n = 110) were studied. The variables were: body mass index, analytical parameters, liver disease etiology, and complications. Liver dysfunction was evaluated using the Child-Pugh Scale. Nutritional state was studied using the Controlling Nutritional Status (CONUT), the Spanish Society of Parenteral and Enteral Nutrition (SENPE) criteria, the Nutritional Risk Index (NRI), the Prognostic Nutritional Index (PNI-O), and the Subjective Global Assessment (SGA). Agreement was determined using the Kappa index. Area under receiver operator characteristic curves (AUCs), the Youden index (J), and likelihood ratios were computed.

RESULTS

Malnutrition varied depending on the method of evaluation. The highest value was detected using the CONUT (90.9%) and the lowest using the SGA (50.9%). The pairwise agreement among the methods ranged from K = 0.041 to K = 0.826, with an overall agreement of each criteria with the remaining methods between K = 0.093 and K = 0.364. PNI-O was the method with the highest overall agreement. Taking this level of agreement into account, we chose the PNI-O as a benchmark method of comparison. The highest positive likelihood ratio for the diagnosis of malnutrition was obtained from the Nutritional Risk Index (13.56).

CONCLUSIONS

Malnutrition prevalence is high and prevalence estimates vary according the method used, with low concordance among methods. PNI-O and NRI are the most consistent methods to identify malnutrition in these patients.

Caracterização sociodemográfica e clínica de candidatos a transplante de fígado

Resumo Objetivo Com o propósito de gerar evidências que contribuam para a prática clínica do enfermeiro na implementação de intervenções direcionadas para a melhoria do cuidado, o presente estudo teve como objetivo analisar dados sociodemográficos e clínicos de candidatos ao transplante de fígado. Métodos Estudo transversal, prospectivo, conduzido em hospital terciário do interior paulista. No início da coleta de dados, 77 pacientes estavam registrados na lista de espera, entretanto o cadastro é dinâmico. Assim, o tipo de amostra foi de conveniência com a participação de 85 candidatos. Resultados A maioria da amostra era do sexo masculino, casada e cursou até o ensino fundamental. O valor médio do Model for End-stage Liver Disease foi de 15,75 pontos, 70,60% dos candidatos estavam acima do peso, sendo a causa viral a principal etiologia da doença hepática crônica. As principais manifestações clínicas apresentadas pelos participantes foram varizes esofágicas, fadiga e ginecomastia nos homens. Conclusão O conhecimento das características de candidatos a transplante de fígado poderá subsidiar o direcionamento de ações de enfermagem com vistas à adoção de condutas individualizadas possibilitando a melhoria da atenção à saúde.

Liver Transplantation in India: At the Crossroads

As the liver transplant journey in India reaches substantial numbers and suggests quality technical expertise, it is time to dispassionately look at the big picture, identify problems, and consider corrective measures for the future. Several features characterize the current scenario. Although the proportion of deceased donor liver transplants is increasing, besides major regional imbalances, the activity is heavily loaded in favor of the private sector and live donor transplants. The high costs of the procedure, the poor participation of public hospitals, the lack of a national registry, and outcomes reporting are issues of concern. Organ sharing protocols currently based on chronology or institutional rotation need to move to a more justiciable severity-based system. Several measures can expand the deceased donor pool. The safety of the living donor continues to need close scrutiny and focus. Multiple medical challenges unique to the Indian situation are also being thrown up. Although many of the deficits demand state intervention and policy changes the transplant community needs to take notice and highlight them. The future of liver transplantation in India should move toward a more accountable, equitable, and accessible form. We owe this to our citizens who have shown tremendous faith in us by volunteering to be living donors as well as consenting for deceased donation.

Health-related quality of life measurement in chronic liver disease patients

BACKGROUND AND OBJECTIVE

Health-related quality of life (HRQOL) is an important health indicator in medical outcome research and clinical practice. This issue tends to attract even more attention with the recent improvements of patient survival after liver transplantation. This review article aims at providing a deeper insight into practices used for evaluating HRQOL in chronic liver diseases (CLDs) and especially cirrhosis patients during different stages of the disease including liver transplantation.

MATERIALS AND METHODS

A systematic review of the MEDLINE database and Cochrane library was conducted. A search using the Medical Subject Headings (MeSH) major terms "liver disease" AND "quality of life" was applied for the period from 1966 to 2012.

RESULTS

Our review identified 1483 publications. The searched showed that significant increase of publications (from 362 to 1018) was observed during last decade (period 2003-2012) in comparison with previous. The majority of publications were in English (n=1179). The literature search and analysis provided information on the most common generic and disease-specific HRQOL instruments, which are used in CLD patients: Medical Outcomes Study Short Form-36, the National Institute of Diabetes and Digestive and Kidney Diseases Quality of Life questionnaire, the Chronic Liver Disease questionnaire, the Liver Disease Quality of Life questionnaire, and other.

CONCLUSIONS

Quality of life instruments are potentially powerful tools for evaluating the functional status, presenting gains of treatment and reflecting patients' ability to return to a normal lifestyle in CLD patients. More attention should be paid by clinicians for integrated use of clinical tests together with HRQOL instruments in liver transplantation for establishing the reference levels of mental, physical, and role-social functioning.