Published online Oct 27, 2020. doi: 10.4254/wjh.v12.i10.829
Peer-review started: May 25, 2020
First decision: June 12, 2020
Revised: July 6, 2020
Accepted: September 4, 2020
Article in press: September 4, 2020
Published online: October 27, 2020
While often understated when compared to other complications of chronic liver disease, malnutrition appears to be a silent but key contributor to survival and quality of life in patients with cirrhosis. Although the field is currently gathering momentum, the available data are still scarce and there is a dire need for standardized evaluation and therapeutic approach.
The focus of our research was to assess the real life impact of malnutrition on survival in a group of cirrhotic patients and to observe whether adherence to current nutritional recommendations alters their outcome.
The aims of the current research were to determine the prevalence of malnutrition in a consecutive series of cirrhotic patients and to determine its impact on survival. Furthermore, we wanted to evaluate whether adherence to current nutritional recommendations improves their outcome. By answering these clinical questions, we tried to set a working baseline, hoping to provide a solid starting point for future research in the field.
Malnutrition was assessed using the Subjective Global Assessment criteria and the mid-arm circumference. These are easy-to-use, cost efficient, bedside methods with extensive prior validation and standardization. Furthermore, dietary habits were evaluated using a comprehensive food intake questionnaire adapted to the specifics of our culture. Total energy and main nutrient intake were calculated based on their response. Patients were followed-up for a median of 27 mo and factors associated with their prognosis were accounted for in uni- and multivariate analysis.
Malnutrition was highly prevalent in patients with cirrhosis and a current or prior decompensating event (68.4%). In comparison, only 13.6% of patients with no history of decompensation were malnourished (P < 0.001). While the overall mortality in our whole group was 70% after a median follow-up of 27 mo, patients with malnutrition had a significantly worse outcome: 50% mortality at 1 year and 63% at 2 years for the patients with malnutrition, compared to 21% at 1 year and 30% at 2 years for patients without malnutrition (P = 0.01). On multivariate analysis, adherence to nutritional recommendations was associated with a better prognosis.
Our results reflect the important burden of malnutrition in patients with advanced liver disease, especially in the setting of a decompensating event. Consequently, a more attentive approach to nutrition should complement pharmacologic and interventional therapy in patients with cirrhosis, as it appears to have a significant impact on survival.
Further research should try to translate more basic research findings into clinical practice, while clinical studies should try to provide solid grounding for guideline recommendations. In this light, there is a dire need for large scale high-quality, multicentric studies on easy-to-use, non-invasive and cost-efficient methods to screen for and grade malnutrition. Not least, dietary habits of patients with advanced liver disease should be thoroughly examined, in order to provide realistic, easy to follow nutritional recommendation in order to increase adherence.