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Mendez-Guerrero O, Carranza-Carrasco A, Chi-Cervera LA, Torre A, Navarro-Alvarez N. Optimizing nutrition in hepatic cirrhosis: A comprehensive assessment and care approach. World J Gastroenterol 2024; 30:1313-1328. [PMID: 38596498 PMCID: PMC11000076 DOI: 10.3748/wjg.v30.i10.1313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/23/2024] [Accepted: 02/25/2024] [Indexed: 03/14/2024] Open
Abstract
Cirrhosis is considered a growing cause of morbidity and mortality, which represents a significant public health problem. Currently, there is no effective treatment to reverse cirrhosis. Treatment primarily centers on addressing the underlying liver condition, monitoring, and managing portal hypertension-related complications, and evaluating the potential for liver transplantation in cases of decompensated cirrhosis, marked by rapid progression and the emergence of complications like variceal bleeding, hepatic encephalopathy, ascites, malnutrition, and more. Malnutrition, a prevalent complication across all disease stages, is often underdiagnosed in cirrhosis due to the complexities of nutritional assessment in patients with fluid retention and/or obesity, despite its crucial impact on prognosis. Increasing emphasis has been placed on the collaboration of nutritionists within hepatology and Liver transplant teams to deliver comprehensive care, a practice that has shown to improve outcomes. This review covers appropriate screening and assessment methods for evaluating the nutritional status of this population, diagnostic approaches for malnutrition, and context-specific nutrition treatments. It also discusses evidence-based recommendations for supplementation and physical exercise, both essential elements of the standard care provided to cirrhotic patients.
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Affiliation(s)
- Osvely Mendez-Guerrero
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Anaisa Carranza-Carrasco
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Luis Alberto Chi-Cervera
- Clínica de Especialidades Gastrointestinales y Hepáticas, Hospital Star Medica, Merida 97133, Yucatan, Mexico
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Nalu Navarro-Alvarez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Molecular Biology, Universidad Panamericana School of Medicine, Campus México, Mexico City 03920, Mexico
- Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO 80045, United States
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JAVAID N, KHAN Z, ALI MA, TAHIR SK. EVALUATING THE IMPACT OF EARLY NUTRITIONAL ASSESSMENT AND INTERVENTION IN HOSPITALIZED LIVER CIRRHOSIS PATIENTS. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:22-28. [PMID: 35442331 DOI: 10.1590/s0004-2803.202200001-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/03/2021] [Indexed: 11/22/2022]
Abstract
ABSTRACT Background Malnutrition is common in liver cirrhosis patients that is correlated with early complications, morbidity and mortality. Objective The purpose of the study was to assess nutritional status, impact of nutritional screening and intervention in liver cirrhosis patients by evaluating their actual energy and protein intake during hospital stay. Methods A cross sectional study was conducted wherein all patients’ nutritional status was defined by Subjective Global Assessment tool. Adequate energy and protein supply were planned and executed by using individualized nutritional plan for patients with dietitian’s collaboration. Anthropometric measurements included height, weight, body mass index, mid upper arm circumference, hand grip strength and triceps skin-fold thickness. Biochemical tests included haemoglobin, mean corpuscular haemoglobin, volume and concentration, albumin and liver function tests. To record the daily food intake, a 24-hour dietary recall was used. Results Overall 83 patients (mean age 55) were included, among them 46% of patients were moderately malnourished, 12% were normal, while 42% of cirrhotic patients were severely depleted according to Subjective Global Assessment. The mean intake of calories and protein was improved during stay in hospital after nutritional intervention and critical monitoring (P<0.05). Anthropometric measurements at baseline and discharge showed significant differences (P <0.05) in weight, body mass index, triceps skin fold thickness and mid upper arm circumference values, but not in hand grip strength that was associated with malnourishment among patients. Conclusion Providing individualized nutritional intervention and its monitoring by qualified dietitians during hospital stay helps to improve intake in patients that prevent further risk of malnutrition and related complications.
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Affiliation(s)
| | - Zahra KHAN
- University of Veterinary and Animal Sciences, Pakistan
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Royal Free Hospital-Nutritional Prioritizing Tool improves the prediction of malnutrition risk outcomes in liver cirrhosis patients compared with Nutritional Risk Screening 2002. Br J Nutr 2020; 124:1293-1302. [PMID: 32600494 PMCID: PMC7656665 DOI: 10.1017/s0007114520002366] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines recommend the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) to identify malnutrition risk in patients with liver disease. However, little is known about the application of the RFH-NPT to screen for the risk of malnutrition in China, where patients primarily suffer from hepatitis virus-related cirrhosis. A total of 155 cirrhosis patients without liver cancer or uncontrolled co-morbid illness were enrolled in this prospective study. We administered the Nutritional Risk Screening 2002 (NRS-2002), RFH-NPT, Malnutrition Universal Screening Tool (MUST) and Liver Disease Undernutrition Screening Tool (LDUST) to the patients within 24 h after admission and performed follow-up observations for 1·5 years. The RFH-NPT and NRS-2002 had higher sensitivities (64·8 and 52·4 %) and specificities (60 and 70 %) than the other tools with regard to screening for malnutrition risk in cirrhotic patients. The prevalence of nutritional risk was higher under the use of the RFH-NPT against the NRS-2002 (63 v. 51 %). The RFH-NPT tended more easily to detect malnutrition risk in patients with advanced Child–Pugh classes (B and C) and lower Model for End-stage Liver Disease scores (<15) compared with NRS-2002. RFH-NPT score was an independent predictive factor for mortality. Patients identified as being at high malnutrition risk with the RFH-NPT had a higher mortality rate than those at low risk; the same result was not obtained with the NRS-2002. Therefore, we suggest that using the RFH-NPT improves the ability of clinicians to predict malnutrition risk in patients with cirrhosis primarily caused by hepatitis virus infection at an earlier stage.
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Dağ Z, Köseoğlu H, Kekilli M. The use of prealbumin as a predictor of malnutrition in cirrhotic patients and the effect of nutritional support in patients with low prealbumin levels. Turk J Med Sci 2020; 50:398-404. [PMID: 32093441 PMCID: PMC7164752 DOI: 10.3906/sag-1910-27] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 02/19/2020] [Indexed: 12/17/2022] Open
Abstract
Background/aim Malnutrition is an important and commonly seen prognostic factor in patients with cirrhosis. The diagnosis of malnutrition in cirrhosis patients may be challenging, and an easily measured and widely usable marker is lacking. Prealbumin, however, is an easily measured marker. In the current study we measured prealbumin levels in cirrhotic patients with no clinically apparent malnutrition and used it as a malnutrition marker. Another aim of this study was to evaluate the effect of nutritional support on patient with low prealbumin levels. Materials and methods Fifty-two patients with Child A and Child B cirrhosis were selected for the study. Prealbumin levels were studied, and Child and MELD scores were calculated. Patients with prealbumin levels ˂180 mg/L were considered to have malnutrition, and two different types of nutritional products were given to these patients. The patients given nutritional support were investigated a month later, and parameters were compared. Results According to the prealbumin threshold of 180 mg/L, malnutrition frequencies were 59.3% for Child A and 95% for Child B cirrhosis. After the provision of nutritional support statistically significant improvements in albumin and INR levels were detected. In addition, the MELD score decreased; however, it was not statistically significant (P: 0.088). A statistically significant decrease in the MELD score was only obtained in patients with Child B cirrhosis (P: 0.033). When the oral replacement therapies were investigated separately, a statistically significant decrease in MELD scores was detected with product 1 (P: 0.043). Conclusion Prealbumin can be used as an easily measured parameter for earlier detection of malnutrition in patients with cirrhosis and without clinically apparent malnutrition. Oral nutritional support, especially with products containing relatively high carbohydrate levels and low protein, may have a favorable effect on MELD scores.
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Affiliation(s)
- Zuhal Dağ
- Department of Internal Medicine, Erol Olçok Education and Research Hospital, Çorum, Turkey
| | - Hüseyin Köseoğlu
- Department of Gastroenterology, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Murat Kekilli
- Department of Gastroenterology, Ankara Education and Research Hospital, Ankara, Turkey
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Hamed AE, Elsahar M, Elwan NM, El-Nakeep S, Naguib M, Soliman HH, Ahmed Aboubakr A, AbdelMaqsod A, Sedrak H, Assaad SN, Elwakil R, Esmat G, Salh S, Mostafa T, Mogawer S, Sadek SE, Saber MM, Ezelarab H, Mahmoud AA, Sultan S, El Kassas M, Kamal E, ElSayed NM, Moussa S. Managing diabetes and liver disease association. Arab J Gastroenterol 2018; 19:166-179. [PMID: 30420265 DOI: 10.1016/j.ajg.2018.08.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/26/2018] [Indexed: 02/05/2023]
Abstract
There is strong association between liver diseases and diabetes (DM) which is higher than expected by a chance association of two very common disorders. It can be classified into three categories: Liver disease related to diabetes, hepatogenous diabetes (HD), and liver disease occurring coincidentally with DM. The criteria for the diagnosis of diabetes associating liver disease are the same for primary diabetes. Two hours post glucose load is a better screening test for HD. HbA1c may not be suitable for diagnosis or monitoring of diabetes associating advanced liver disease. Apart from the increased cardiovascular risk in patients with type 2 DM (T2 DM) and NAFLD, the cardiovascular and retinopathy risk is low in HD. Patients with metabolic derangement should be screened for NAFLD which in turn may predict T2 DM development. Similarly, patients with established T2 DM should also be screened for NAFLD which further contributes to diabetes worsening. Diabetes is a significant risk factor for progression of the chronic liver disease. It is associated with poor patient survival. Treatment of diabetes associating liver disease appears beneficial. Metformin, if tolerated and not contraindicated, is recommended as a first-line therapy for patients with diabetes and chronic liver disease (CLD). If the hepatic disease is severe, insulin secretagogues should be avoided because of the increased risk of hypoglycaemia. Pioglitazone may be useful in patients with fatty liver disease. DPP-4 inhibitors showed effectiveness and safety for the treatment of T2 DM in CLD patients up to those with child B stage. GLP-1 receptor agonists and SGLT-2 inhibitors exhibit positive effects on weight and are associated with minimal risk of hypoglycaemia. Insulin must be used with caution, as hypoglycaemia may be a problem. Insulin analogues are preferred in the context of hypoglycaemia Statins can be used to treat dyslipidaemia in NAFLD, also the use of angiotensin II receptor antagonist for hypertension is safe and beneficial Given the clear association between diabetes mellitus and hepatocellular carcinoma, the strict control of glycaemia with insulin sensitizers can be essential in its prevention. The addition of DM to the currently used scores (Child-Pugh and MELD scores) may enhance the sensitivity and the specificity for prediction of morbidity and mortality rates in cirrhotic patients. In the new era of directly acting antiviral agents (DAAs) for HCV treatment, it is recommended to follow up lipid profile and blood sugar levels following SVR in order to adjust doses of medications used in diabetic (SVR is associated with reduction in insulin requirements) and dyslipidaemic patients (rebound increase in the lipid profile after clearing the virus may increase risk of cardiovascular disease (CVD)). The issues of post liver transplant diabetes and relation between DM and chronic HBV are highlighted. This narrative review and Consensus-based practice guidance (under revision and criticism) are based on a formal review and analysis of the recently published world literature on the topic (Medline search up to September 2017); and the experience of the authors and independent reviewers.
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Affiliation(s)
- Abd Elkhalek Hamed
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt.
| | - Medhat Elsahar
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Police Medical Academy, Egypt
| | | | | | | | | | - Ashraf Ahmed Aboubakr
- Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt
| | | | | | | | - Reda Elwakil
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Ain Shams University, Egypt
| | - Gamal Esmat
- The Egyptian Association for the Study of Liver and Gastrointestinal Disease (EASLGD), Egypt; Kasr Al Aini, Egypt
| | - Samira Salh
- Department of Pharmacy, Cairo University, Egypt
| | | | | | - Sameh Emil Sadek
- Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt
| | - Maha M Saber
- Department of Clinical Nutrition National Research Centre, Egypt
| | - Hanan Ezelarab
- Department of Clinical Nutrition National Research Centre, Egypt
| | - Asem Ashraf Mahmoud
- Department of Internal Medicine, Hepatology, and Diabetes, Egyptian Military Medical Academy, Egypt
| | | | | | - Ehab Kamal
- Medical Department, National Research Centre, Egypt
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Comparing assessment tools for detecting undernutrition in patients with liver cirrhosis. Clin Nutr ESPEN 2017; 23:156-161. [PMID: 29460792 DOI: 10.1016/j.clnesp.2017.10.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 08/01/2017] [Accepted: 10/20/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIMS Undernutrition in cirrhotic patients is often poorly recognised until late-stages. The current UK screening tool, the Malnutrition Universal Screening Tool, can miss undernutrition in patients with ascites/fluid retention. A 6-question Liver Disease Undernutrition Screening Tool (LDUST) has been developed in America. METHODS We sought to compare LDUST with MUST in the detection of undernutrition in 50 inpatients and 50 outpatients with liver cirrhosis in a secondary care setting. This was then validated by a dietitian assessment. RESULTS Similar patient demographics and liver disease aetiologies were found in the two cohorts. Mean Child-Pugh scores were higher for inpatients, 8.3 (SD 1.9) vs 5.9 (SD 1.2). LDUST detected undernutrition in 45/50 inpatients (90%) and 34/50 outpatients (68%). MUST scores ≥2 were present in 19/50 (38%) inpatients and 9/50 (18%) outpatients. In those with a MUST score <2, LDUST detected undernutrition in 26/31 (84%) inpatients and 27/41 (66%) outpatients. 26 inpatients had undernutrition using LDUST but had a MUST score <2, 20 (76%) of these were deemed to be undernourished by dietetics assessment. LDUST was mostly completed independently or with minimal assistance (80% inpatients, 100% outpatients), with mean completion times of 4 and 3 min for in- and outpatients respectively. CONCLUSION LDUST is a quick and easy screening tool, which appears better able than MUST to detect undernutrition in cirrhotic patients, including undernutrition missed by MUST. Importantly the tool was validated against dietitian assessments. The high rates of undernutrition among cirrhotic inpatients suggest that screening this cohort is unnecessary, and instead all should undergo dietitian review, with LDUST utilised in an outpatient setting.
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