Role of Nutrition In Acute Alcoholic Hepatitis: A Quality Improvement Project

Abstract

Introduction: Malnutrition is a common cause of impeding recovery in patients with acute alcoholic hepatitis (AAH). Previous reports have shown that appropriate nutritional supplementation reduces mortality in patients with AAH. Current guidelines by the American Gastroenterology Association (AGA) recommend a “1-1.5 g protein and 30-40 kcal/kg body weight” daily intake for adequate recovery. Despite these clear recommendations, the element of nutrition in AAH is often neglected. Methods: We designed a quality improvement project to evaluate and improve compliance with appropriate nutrition in patients presenting with AAH at our institution. Patients admitted with AAH between December, 2015 to December, 2016 were included. Baseline characteristics including age, gender, Maddrey discriminant function, and model for end-stage liver disease (MELD) score were noted. Our primary outcome was compliance with appropriate nutrition. Other outcomes including length of stay, mortality and thirty day readmission rates were also noted. Results: A total of 54 patients were included. Only 9 of the 54 patients (17%) received a high calorie and high protein diet. Hepatology was consulted in 76% of the patients, and 21% of these patients received appropriate nutrition as compared to only 8.3% in whom hepatology was not consulted. Nutrition was consulted in 57% of these patients and 67% of those patients received appropriate nutrition. All-cause mortality for AAH was 13%. The average length of stay for patients with appropriate nutrition group was approximately 12 days as compared to 10 days for those with inadequate nutrition. Readmission within thirty days for patients who received appropriate nutrition was 44% (4/9) compared to 22% in those who with inadequate nutrition (10/45). Conclusion: Our compliance of appropriate nutrition in AAH is low. This is likely due to several reasons: i) knowledge gap among physicians, ii) low priority to nutrition from physicians, iii) lack of patient understanding of their nutritional needs, iv), lack of standardized nutrition protocol. Our initial investigation suggest that hepatology and nutrition consultation improved compliance with appropriate nutrition. A process map of improving compliance with appropriate nutrition in AAH has been developed and areas for intervention have been identified. The next step will be to implement protocolized care for appropriate nutrition in AAH, and re-examine adherence and patient outcomes.