Enteral Nutrition Support for Sarcopenia in End-Stage Liver Disease

Abstract

Introduction: Weight loss with muscle wasting, also known as sarcopenia, commonly occurs in patients with end-stage liver disease (ESLD). A robust association between sacropenia and mortality in cirrhotic and post-liver transplant patients has been reported. This is a report of a patient with severe sacropenia and ESLD who was provided enteral nutrition using a Dobhoff tube (DHT) pre-liver transplant, resulting in successful bridging to transplant. Case Report: A 59-year-old male with chronic hepatitis C-related cirrhosis was awaiting liver/kidney transplant. Complications of his ESLD included hepatorenal syndrome, recurrent admissions for hepatic encephalopathy, variceal bleeding, and refractory ascites. In addition, the patient had continued to lose weight. The patient reported poor appetite and decreased oral intake. His body mass index (BMI) had fallen to 17.2 kg/m2 and raised concern by our transplant team about his ability to survive transplantation. Past surgical and family histories were unremarkable. Physical examination was notable for cachexia, temporal and thenar wasting, moderate abdominal distension, and lower extremity edema. Significant laboratory data included a pre-albumin of 6.0 mg/dL and albumin of 2.1 g/dL. Pre-transplant computed tomography of the abdomen and pelvis (CT a/p) of this patient revealed a mean total psoas area (TPA) of 820.70 mm2, indicating severe sarcopenia. A DHT was placed to improve his nutritional status and allow for home enteral feeding. The DHT was secured with a nasal bridle system (NBS) to prevent tube dislodgement. With enteral feeding, in addition to oral intake, the patient reported feeling less fatigued and lethargic. He gained 3 lbs, albumin rose to 3.0 g/dL, and he was not hospitalized until 1 month later, when he underwent successful simultaneous liver and renal transplant. Discussion: As previously reported, there is an increased incidence of perioperative morbidity and mortality associated with a low psoas muscle area, as measured on CT a/p at the level of the L4 vertebra. This case demonstrates that home enteral nutrition supplementation with a DHT is an option to be considered for improving a patient’s nutritional status pre-liver transplant. Although complications such as vomiting, diarrhea, and gastrointestinal bleeding are possible with this intervention, it is overall low-risk with regard to infection. DHT for supplemental enteral feeding should be considered in patients with pre-transplant sarcopenia to preserve their candidacy as a transplant candidate. Well-designed trials are needed to study this intervention to determine its overall effectiveness.