Observational Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Oct 27, 2020; 12(10): 829-840
Published online Oct 27, 2020. doi: 10.4254/wjh.v12.i10.829
Malnutrition and non-compliance to nutritional recommendations in patients with cirrhosis are associated with a lower survival
Dana Crisan, Bogdan Procopet, Alexandra Epure, Horia Stefanescu, Alina Suciu, Andreea Fodor, Emil Mois, Rares Craciun, Nicolae Crisan
Dana Crisan, Nicolae Crisan, Internal Medicine Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca 400126, Romania
Bogdan Procopet, Alexandra Epure, Alina Suciu, Andreea Fodor, 3rd Medical Clinic, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca 400126, Romania
Bogdan Procopet, Horia Stefanescu, Hepatology Unit, “Prof. Dr. Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
Emil Mois, Surgery Department, “Prof. Dr. Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400126, Romania
Rares Craciun, Hepatology Unit , “Prof. Dr. Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400126, Romania
Author contributions: Crisan D, Procopet B, Stefanescu H and Crisan N had key contributions in the conception and design of the study and have provided a critical revision of the manuscript for important intellectual content; Epure A, Suciu A, Fodor A and Mois E have performed the nutritional assessment; have applied the nutritional recommendations adherence questionnaires and worked on data acquisition; Crisan D, Procopet B and Craciun R have contributed to analysis and interpretation of the data and drafting the manuscript; all authors gave their final approval of the version to be submitted and agree to be accountable for all aspects of the work.
Institutional review board statement: The study was reviewed and approved by the “Iuliu Hatieganu” University of Medicine and Pharmacy.
Informed consent statement: Participants were informed about the plan about our study details. And if they agreed to participate in, written informed consent was obtained from each participant prior to their inclusion in the study.
Conflict-of-interest statement: There are no conflicts of interest to report.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement checklist of items and prepared and revised the manuscript accordingly.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Bogdan Procopet, MD, PhD, Doctor, Senior Lecturer, Staff Physician, 3rd Medical Clinic, “Iuliu Hatieganu” University of Medicine and Pharmacy, 19-21 Croitorilor Street, Cluj-Napoca 400126, Romania. bogdan.procopet@umfcluj.ro
Received: May 25, 2020
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
Processing time: 151 Days and 11.5 Hours
Research background

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.

Research motivation

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.

Research objectives

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.

Research methods

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.

Research results

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.

Research conclusions

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.

Research perspectives

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.