Validation of Malnutrition Screening Tools in Liver Cirrhosis

Identifying malnutrition risk in hospitalized patients: an analysis of five tools in the light of GLIM criteria

BACKGROUND

The prompt identification of malnutrition among hospitalized patients using the appropriate screening tool is paramount. The objective of our study is to compare the most recommended screening tools concerning the new GLIM criteria for malnutrition in hospitalized patients.

METHODS

In this cross-sectional study, we analyzed the data on 1,397 patients receiving inpatient treatment at Bandırma Training and Research Hospital between August 2022 and May 2023 to assess and compare malnutrition in them. Patients who received inpatient treatment in the internal and surgical clinics of Bandırma Training and Research Hospital. In addition to the GLIM criteria, we used nutritional screening and assessment tools such as NRS-2002, MST, GMS, MUST, and SNAQ. The GLIM criteria were considered the gold standard for the evaluation of sensitivity and specificity. Receiver operating characteristic (ROC) curves for the five screening tools were also used to assess the ability to distinguish malnutrition-risk patients accurately.

RESULTS

The comparison of the performances of different screening tools in detecting malnutrition demonstrated that while the GMS had the highest sensitivity (87.40%), the NRS-2002 had the highest specificity (91.70%). The area under the Curve (AUC) value indicated that the predictive values of the NRS-2002, MST, GMS, and SNAQ were excellent, and the predictive value of the MUST was good (p < 0.001). While the GLIM criteria in particular appear to be an effective tool for detecting malnutrition in hospitalized individuals, other screening tools are also useful in assessing their malnutrition risk.

CONCLUSIONS

We emphasized MST's alignment with GLIM criteria, underscoring the importance of a multidisciplinary approach for early malnutrition diagnosis. Patients at risk of malnutrition can be diagnosed more quickly and accurately with appropriate screening tools and the effectiveness of treatments can be increased.

Comparison of different nutritional screening tools in nutritional screening of patients with cirrhosis: A cross-sectional observational study

Aims

The Royal Free Hospital Nutritional Prioritizing Tool (RFH-NPT), the Liver Disease Undernutrition Screening Tool (LDUST) and Nutritional Risk Screening 2002 (NRS2002) were used by nurses to screen, compare, and analyze the nutritional status of patients with liver cirrhosis. The application value of different screening tools was summarized in the nutritional screening of patients with liver cirrhosis.

Methods

In this study, LDUST, RFH-NPT, and NRS2002 were used by nurses to screen the nutritional status of hospitalized patients with liver cirrhosis within 24-48 h after admission. The study calculated validity indicators such as sensitivity, specificity, the area under the receiver operating curve (AUC), and reliability indicators such as the Kappa coefficient. The efficacy of these screening tools in the nutritional screening of patients with liver cirrhosis was compared.

Results

Among the 207 patients, LDUST and NRS2002 identified 72.9 % and 23.7 % as undernourished, respectively. The sensitivity of LDUST and NRS2002 were 92.1 % and 30.0 %, respectively. The Kappa value of LDUST and RFH-NPT was 0.620, and the Kappa value of LDUST compared with NRS2002 was 0.144.

Conclusion

This study shows that the Liver Disease Undernutrition Screening Tool, a special screening tool for patients with liver cirrhosis, has a more reliable screening effect and higher sensitivity than NRS2002. The Liver Disease Undernutrition Screening Tool is recommended for nutritional screening in patients with liver cirrhosis.

Identifying nutrition risk in emergency patients: What is the most appropriate screening tool?

BACKGROUND

The emergency department (ED) is the most frequent access route to the hospital. Nutrition risk (NR) screening allows the early identification of patients at risk of malnutrition. This study aimed to evaluate the feasibility and predictive validity of five different tools in EDs: Nutritional Risk Screening 2002 (NRS-2002), Nutritional Risk Emergency 2017 (NRE-2017), Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT), Malnutrition Universal Screening (MUST), and Malnutrition Screening Tool (MST).

METHODS

Patients with scores ≥3 according to the NRS-2002, ≥1.5 according to the NRE-2017, and ≥2 according to the MUST, RFH-NPT, or MST were classified with NR. Prolonged length of stay (LOS) and 1-year mortality were evaluated.

RESULTS

431 patients were evaluated (57.31 ± 15.6 years of age; 54.4% women) in a public hospital in southern Brazil. The prevalence of NR was: 35% according to the NRS-2002, 43% according to the MST, 45% according to the NRE-2017 and MUST, and 49% according to the RFH-NPT. Patients with NR, had a greater risk of prolonged LOS (P < 0.001). The presence of NR was associated with an increased risk of 1-year mortality according to the NRS-2002 (hazard ratio [HR]: 4.04; 95% CI, 2.513-6.503), MST (HR: 2.60; 95% CI, 1.701-3.996), NRE-2017 (HR: 4.82; 95% CI, 2.753-8.443), MUST (HR: 4.00; 95% CI, 2.385-6.710), and RFH-NPT (HR: 5.43; 95% CI, 2.984-9.907).

CONCLUSIONS

NRE-2017 does not require objective data and presented predictive validity for all outcomes assessed, regardless of the severity of the disease, and thus appears to be the most appropriate tool for carrying out NR screening in the ED.

Nutritional aspects of prehabilitation in adults with cirrhosis awaiting liver transplant

Malnutrition, sarcopenia (low muscle mass), and physical frailty have gained increasing recognition in candidates for liver transplant (LT) as these conditions can impact postoperative functional capacity. Multidimensional prehabilitation programs have been proposed as a safe intervention in adults awaiting LT but the nutritional pillar of prehabilitation has been understudied. This review summarizes the nutritional recommendations for prehabilitation for individuals with cirrhosis awaiting LT. Three major aspects of nutritional prehabilitation are discussed: (1) Assess: Evaluate nutritional status and assess for malnutrition, sarcopenia, and frailty to guide the nutritional prehabilitation intervention intensity, increasing across universal, targeted, and specialist levels; (2) Intervene: Prescribe a nutritional prehabilitation intervention to meet established nutrition guidelines in cirrhosis with a targeted focus on improving nutritional status and muscle health; (3) Reassess: Follow-up based on the required intensity of nutritional care with as needed intervention adjustment. Topics covered in the review include nutritional care levels for prehabilitation, energy prescriptions across body mass index strata, detailed considerations around protein intake (amount, distribution, and quality), carbohydrate and fat intake, other nutritional considerations, and the potential role of dietary supplements and nutraceuticals. Future research is warranted to more accurately evaluate energy needs, evaluate emerging dietary supplementation strategies, and establish the role of nutraceuticals alongside food-based interventions. While the general principles of nutritional prehabilitation are ready for immediate application, future large-scale randomized controlled trials in this space will help to quantify the benefit that can be gained by transitioning the LT approach from passive "transplant waitlist time" to active "transplant preparation time."

Analysis of ESPEN and GLIM algorithms reveals specific drivers for the diagnosis of malnutrition in patients with chronic gastrointestinal diseases

OBJECTIVES

Disease-related malnutrition (MN) is common in patients with liver cirrhosis (LC), short bowel syndrome (SBS), and chronic pancreatitis (CP). Different MN risk screening tools and diagnostic criteria of the European Society for Clinical Nutrition and Metabolism (ESPEN) and Global Leadership Initiative on Malnutrition (GLIM) algorithms were analyzed for their diagnostic accuracy and role as specific drivers to diagnose MN in patients with LC, SBS, and CP.

METHODS

A total of 187 patients with LC, SBS, and CP, as well as control patients were prospectively recruited in a multicenter cross-sectional study. MN risk was screened using Nutritional Risk Screening 2002 (NRS-2002), the Malnutrition Universal Screening Tool (MUST), and the Royal Free Hospital Nutritional Prioritizing Tool (RFH-NPT), and diagnosed using the ESPEN, GLIM, and GLIM^CRP+ (GLIM incorporating C-reactive protein [CRP] >5 mg/L) algorithms. For each of the individual diagnostic criteria, relative frequency, sensitivity, specificity, as well as positive and negative predictive values were calculated.

RESULTS

NRS-2002 was only sensitive in conjunction with ESPEN, while MUST was sensitive additionally with the GLIM algorithm. RFH-NPT worked the best for LC. GLIM and GLIM^CRP+ diagnosed MN more frequently than the ESPEN algorithm. Diagnostic criteria were detected at remarkably different relative frequencies starting with reduced food intake/malabsorption and chronic disease/inflammation, followed by weight loss, reduced fat-free mass index, low body mass index, and body mass index <18.5 kg/m². Relative frequencies differed between LC, SBS, and CP. Weight loss in LC and CP and reduced fat-free mass index and food intake in SBS had good diagnostic accuracy, suggesting that these criteria act as specific drivers for MN.

CONCLUSIONS

RFH-NPT and MUST performed better in conjunction with the GLIM algorithm than NRS-2002. MN was diagnosed more frequently by GLIM than the ESPEN algorithm in LC, SBS, and CP. Individual criteria acted as specific drivers in MN in chronic gastrointestinal diseases.

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.

TRANSLATION AND CROSS-CULTURAL ADAPTATION OF THE ROYAL FREE HOSPITAL-NUTRITIONAL PRIORITIZING TOOL (RFH-NPT)

BACKGROUND

Nutritional screening is defined by American Society for Parenteral and Enteral Nutrition (ASPEN) as a process to identify individuals at risk of malnutrition. Malnutrition is a prevalent condition in cirrhotic patients, and it results in important prognostic implications. Most of the commonly used instruments fail in considering the particularities of cirrhotic patients. The Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) is a nutritional screening tool developed and validated to identify malnutrition risk in patients with liver disease.

OBJECTIVE

The study's aim was to conduct the transcultural adaptation (translation and adaptation) of RFH-NPT tool to Portuguese (Brazil).

METHODS

The process of cultural translation and adaptation followed the Beaton et al. methodology. The process involved the steps of initial translation, synthesis translation, back translation pretest of the final version with 40 nutritionists and a specialists committee. The internal consistency was calculated with the Cronbach coefficient and the content validation was verified with the content validation index.

RESULTS

Forty clinical nutritionists with experience in treatment of adult patients participated in the step of cross-cultural adaptation. The alpha Cronbach coefficient was 0.84, which means high reliability. In the specialists analyzes all the tool's questions achieved a validation content index higher than 0.8, showing high agreement.

CONCLUSION

The NFH-NPT tool was translated and adapted to Portuguese (Brazil) and showed high reliability.

Value of the controlling nutritional status score and psoas muscle thickness per height in predicting prognosis in liver transplantation

BACKGROUND

Patients with end-stage liver disease usually have varying degrees of malnutrition, and severe malnutrition may affect the prognosis of patients after liver transplantation (LT). However, there is no recommended standard for the nutrition assessment of patients waiting for LT, and it is unknown whether malnutrition has an impact on the occurrence of postoperative complications.

AIM

The study aim was to investigate the value of the controlling nutritional status (CONUT) score and psoas muscle thickness per height (PMTH) in predicting prognosis in LT.

METHODS

We retrospectively analyzed the clinical data of 313 patients who underwent classic orthotopic LT from January 2016 to December 2018 in Tianjin First Central Hospital affiliated with Tianjin Medical University. The CONUT score is derived from the preoperative serum albumin and total cholesterol levels, and total lymphocyte count. Patients were divided into low (≤ 4), medium (5–8), and high (9–12) CONUT score groups perioperative characteristics, Clavien-Dindo grade III/IV/V postoperative complications, graft loss and infection, and cumulative postoperative survival in the three groups were compared 3 mo after LT. PMTH was calculated as the ratio of the transverse thickness of the psoas muscle in the umbilical plane to the height of the patient. The cutoff values of receiver operating characteristic curves were determined separately for men and women. The values were 14.1 cm/m² for women and 17.9 cm/m² for men. The patients were then divided into low and high PMTH groups by the cutoff values. The comparison of data between the two groups was the same as above.

RESULTS

Patients with medium and high CONUT scores had lower preoperative serum hemoglobin, more intraoperative red blood cell (RBC) transfusions, longer postoperative intensive care unit stay and hospital stays, higher 7 and 14 preoperative-day serum bilirubin levels, and a higher incidence of postoperative grade III/IV complications and infections than patients with low CONUT scores. Differences in the 3-mo cumulative survival among the three groups were not significant. Patients with a low PMTH had higher preoperative serum urea nitrogen, more intraoperative packed RBC and frozen plasma transfusions, longer times to postoperative ventilator extubation, higher incidence of total postoperative complications, and a lower 3-mo cumulative survival than those with a high PMTH.

CONCLUSION

A CONUT score ≥ 5 and a low PMTH were both associated with poor prognosis in LT. The CONUT score had no predictive value for short-term patient survival after LT, but the PMTH was predictive of short-term patient survival after LT.

Visceral Adiposity Associates With Malnutrition Risk Determined by Royal Free Hospital-Nutritional Prioritizing Tool in Cirrhosis

Mounting evidence has suggested the clinical significance of body composition abnormalities in the context of cirrhosis. Herein, we aimed to investigate the association between visceral adiposity and malnutrition risk in 176 hospitalized patients with cirrhosis. The adiposity parameters were obtained by computed tomography (CT) as follows: total adipose tissue index (TATI), visceral adipose tissue index (VATI), subcutaneous adipose tissue index (SATI), and visceral to subcutaneous adipose tissue area ratio (VSR). Malnutrition risk was screened using Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT). Visceral adiposity was determined given a higher VSR based on our previously established cutoffs. Multivariate analysis implicated that male gender (OR = 2.884, 95% CI: 1.360–6.115, p = 0.006), BMI (OR = 0.879, 95% CI: 0.812–0.951, P = 0.001), albumin (OR = 0.934, 95% CI: 0.882–0.989, P = 0.019), and visceral adiposity (OR = 3.413, 95% CI: 1.344–8.670, P = 0.010) were independent risk factors of malnutrition risk. No significant difference was observed regarding TATI, SATI, and VATI among patients with low or moderate and high risk of malnutrition. In contrast, the proportion of male patients embracing visceral adiposity was higher in high malnutrition risk group compared with that in low or moderate group (47.27 vs. 17.86%, p = 0.009). Moreover, this disparity was of borderline statistical significance in women (19.05 vs. 5.88%, p = 0.061). Assessing adipose tissue distribution might potentiate the estimation of malnutrition risk in cirrhotics. It is pivotal to recognize visceral adiposity and develop targeted therapeutic strategies.

Mini Nutritional Assessment - Short Form Is a Useful Malnutrition Screening Tool in Patients with Liver Cirrhosis, Using the Global Leadership Initiative for Malnutrition Criteria as the Gold Standard

BACKGROUND

The use of nutrition-screening tools in cirrhotic patients is not systematized. Recently, specific tools have been proposed for patients with cirrhosis, but their diagnostic capabilities have been scarcely studied.

METHODS

This was a prospective study that includes outpatients with liver cirrhosis undergoing follow-up in the hepatology consultations of a tertiary-care university hospital. A trained gastroenterologist applied the screening tools: Liver Disease Universal Screening Tool (LDUST), Royal Free Hospital-Nutrition Prioritizing Tool (RFH-NPT), and Mini Nutritional Assessment-Short Form (MNA-SF). Subsequently, the diagnosis of malnutrition was made according to Global Leadership Initiative for Malnutrition (GLIM) criteria by an endocrinologist, who was blind to the results of the screening tools.

RESULTS

Sixty-three patients (38.1% women, mean age 63.1 ± 9.9 years) with cirrhosis (60.3% Child-Pugh A, 34.9% Child-Pugh B, and 4.8% Child-Pugh C) were evaluated. The prevalence of malnutrition was 38.1% (15.9% moderate, 22.2% severe). Advanced stages of cirrhosis were associated with a higher prevalence of malnutrition (P = .021). MNA-SF was the most accurate screening tool, being superior to RFH-NPT and LDUST. It presented better sensitivity than RFH-NPT (88% [0.68-0.97] vs 67% [0.45-0.84], P = .031) and better specificity than both LDUST (97% [0.87-0.99] vs 62% [0.45-0.77], P < .001) and RFH-NPT (97% [0.87-0.99] vs 82% [0.67-0.93], P = .016).

CONCLUSIONS

According to the GLIM criteria, malnutrition affected 38.1% of patients with cirrhosis, being severe in 22% of the patients. MNA-SF is the most accurate screening test, superior even to tools specifically designed for cirrhotic patients (LDUST).

Neutrophil-to-lymphocyte ratio is associated with malnutrition risk estimated by the Royal Free Hospital-Nutritional Prioritizing Tool in hospitalized cirrhosis

BACKGROUND

Liver cirrhosis is characterized by immune dysfunction, contributing to malnutrition. We previously revealed neutrophil-to-lymphocyte ratio (NLR) as an indicator of disordered immune system. Herein we aimed to (1) determine the optimal NLR cutoff that best predicts malnutrition risk and (2) clarify the association between NLR and nutrition status.

METHODS

A total of 135 hospitalized patients with cirrhosis were included. Immune dysfunction was evaluated by levels of serum C-reactive protein (CRP), NLR, and other parameters. Malnutrition was screened by a risk score referring to the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT). Receiver operating characteristic (ROC) curve was implemented to determine the best NLR cutoff that predicts malnutrition risk. Correlation between NLR and indicators of hepatic and physical function (handgrip strength) were also examined. Multivariable logistic regression was used to assess the association between NLR and malnutrition risk.

RESULTS

ROC curve revealed that the optimum cutoff to predict malnutrition risk was NLR > 4.2, with a sensitivity of 47.2%, specificity of 81.0%, negative predictive value of 58.0%, and positive predictive value of 74.5%, respectively. Patients with NLR > 4.2 exhibited a higher RFH-NPT score, serum platelet-to-lymphocyte ratio, and CRP. A positive correlation was found between NLR values and Child-Turcotte-Pugh (r = 0.22; P = .010), model for end-stage liver disease (r = 0.36; P < .001), and RFH-NPT scores (r = 0.31; P < .001). NLR was a risk factor for malnutrition independently of alcoholic liver disease and presence of ascites.

CONCLUSIONS

Immune dysfunction measured by NLR was associated with malnutrition risk estimated by RFH-NPT in cirrhosis.

Malnutrition in Patients with Liver Cirrhosis

Liver cirrhosis is an increasing public health threat worldwide. Malnutrition is a serious complication of cirrhosis and is associated with worse outcomes. With this review, we aim to describe the prevalence of malnutrition, pathophysiological mechanisms, diagnostic tools and therapeutic targets to treat malnutrition. Malnutrition is frequently underdiagnosed and occurs-depending on the screening methods used and patient populations studied-in 5-92% of patients. Decreased energy and protein intake, inflammation, malabsorption, altered nutrient metabolism, hypermetabolism, hormonal disturbances and gut microbiome dysbiosis can contribute to malnutrition. The stepwise diagnostic approach includes a rapid prescreen, the use of a specific screening tool, such as the Royal Free Hospital Nutritional Prioritizing Tool and a nutritional assessment by dieticians. General dietary measures-especially the timing of meals-oral nutritional supplements, micronutrient supplementation and the role of amino acids are discussed. In summary malnutrition in cirrhosis is common and needs more attention by health care professionals involved in the care of patients with cirrhosis. Screening and assessment for malnutrition should be carried out regularly in cirrhotic patients, ideally by a multidisciplinary team. Further research is needed to better clarify pathogenic mechanisms such as the role of the gut-liver-axis and to develop targeted therapeutic strategies.

Residual clinical damage after COVID-19: A retrospective and prospective observational cohort study

Data on residual clinical damage after Coronavirus disease-2019 (COVID-19) are lacking. The aims of this study were to investigate whether COVID-19 leaves behind residual dysfunction, and identify patients who might benefit from post-discharge monitoring. All patients aged ≥18 years admitted to the Emergency Department (ED) for COVID-19, and evaluated at post-discharge follow-up between 7 April and 7 May, 2020, were enrolled. Primary outcome was need of follow-up, defined as the presence at follow-up of at least one among: respiratory rate (RR) >20 breaths/min, uncontrolled blood pressure (BP) requiring therapeutic change, moderate to very severe dyspnoea, malnutrition, or new-onset cognitive impairment, according to validated scores. Post-traumatic stress disorder (PTSD) served as secondary outcome. 185 patients were included. Median [interquartile range] time from hospital discharge to follow-up was 23 [20-29] days. 109 (58.9%) patients needed follow-up. At follow-up evaluation, 58 (31.3%) patients were dyspnoeic, 41 (22.2%) tachypnoeic, 10 (5.4%) malnourished, 106 (57.3%) at risk for malnutrition. Forty (21.6%) patients had uncontrolled BP requiring therapeutic change, and 47 (25.4%) new-onset cognitive impairment. PTSD was observed in 41 (22.2%) patients. At regression tree analysis, the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) and body mass index (BMI) at ED presentation, and age emerged as independent predictors of the need of follow-up. Patients with PaO2/FiO2 <324 and BMI ≥33 Kg/m2 had the highest odds to require follow-up. Among hospitalised patients, age ≥63 years, or age <63 plus non-invasive ventilation or diabetes identified those with the highest probability to need follow-up. PTSD was independently predicted by female gender and hospitalisation, the latter being protective (odds ratio, OR, 4.03, 95% confidence interval, CI, 1.76 to 9.47, p 0.0011; OR 0.37, 95% CI 0.14 to 0.92, p 0.033, respectively). COVID-19 leaves behind physical and psychological dysfunctions. Follow-up programmes should be implemented for selected patients.