Nutritional Status Of Cirrhotic Patients Research Articles

Transjugular Intrahepatic Portosystemic Shunt Placement: Effects on Nutritional Status in Cirrhotic Patients.

Malnutrition is a tangible complication of cirrhosis with portal hypertension with a prevalence of up to 50%. In particular, sarcopenia and myosteatosis, defined as the alteration in muscle quantity and quality, have a negative impact on the main complications of liver disease and are associated with higher mortality in patients with cirrhosis. Recently, alterations in adipose tissue have also been described in cirrhotic patients and they seem to influence the course of liver disease. Several pieces of evidence indicate that a transjugular intrahepatic portosystemic shunt (TIPS), placed for the treatment of refractory portal hypertension, can lead to a modification of body composition consisting in the improvement of the skeletal muscle index, myosteatosis, and an increase in subcutaneous fat. These modifications of the nutritional status, even more pronounced in sarcopenic patients before TIPS, have been associated with an amelioration of cognitive impairment after TIPS as well as with an increase in the survival rate. The aim of this paper is to provide an overview of the effects of TIPS placement on nutritional status in cirrhosis focusing on its pathophysiological mechanisms and its relationship with liver-related outcomes.

The Impact of Transjugular Intrahepatic Portosystemic Shunt on Nutrition in Liver Cirrhosis Patients: A Systematic Review.

Liver cirrhosis leads to clinically significant portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) has been shown to effectively reduce the degree of portal hypertension and treat its complications. However, poor nutritional status has been shown to be associated with hepatic encephalopathy, acute on chronic liver failure, and mortality following TIPS placement. The purpose of this systematic review is to create another perspective and evaluate the effect of TIPS placement on the nutritional status of patients with liver cirrhosis. A comprehensive search of four major electronic databases was conducted to identify studies that assessed the nutritional status of cirrhotic patients before and after TIPS placement. The risk of bias was evaluated using ROBINS-I guidelines. Fifteen studies were analyzed in this review. The results indicate that among the 11 studies that evaluated changes in ascites-free weight and body mass index or body cell mass, 10 reported an improvement in one or more measures. Furthermore, all seven studies that evaluated changes in muscle mass demonstrated an increase in muscle mass. Among the four studies that evaluated subcutaneous fat tissue, three showed a significant expansion, while two out of three studies evaluating visceral fat tissue reported a significant reduction. The results of this systematic review suggest that TIPS placement is associated with improvement in the nutritional status of cirrhotic patients, indicated by an increase in ascites-free weight, body mass index, and muscle mass. Additionally, TIPS placement leads to a shift in the distribution of fat mass, with a preference for subcutaneous over visceral adipose tissue. Notably, sarcopenic patients seem to benefit the most from TIPS placement in terms of nutritional status.

Assessment of Severity of Liver Cirrhosis and Nutritional status of Cirrhotic patients in Tribhuvan University Teaching Hospital, Kathmandu

Malnutrition is common in chronic liver disease. The general objective of this study was to assess severity and nutritional status of cirrhotic patients in Tribhuvan University Teaching Hospital (TUTH). A cross-sectional study was carried out among 88 cirrhotic patients of age group of ≥18 years. Information regarding general profile of patient, Child Turcotte Pugh score (CTP), Model for End Stage Liver Diseases-Na Score ( MELD-Na), Subjective Global Assessment (SGA), Mid Arm Circumference (MAC), Triceps Skin Fold Thickness (TST), Mid Arm Muscle Circumference (MAMC) and Functional Assessment: Handgrip Strength (HGS) was collected. SPSS version 20 was used to analyse data. Majority (56.8%) belonged to CTP grade C, 31.8% belonged to CTP grade B and 11.4% patients belonged to CTP grade A. Majority, 72.7%, 71.6% and 65.9% were malnourished when assessed using SGA, TST and MAC respectively. Majority, 86.4% of the patients had impaired handgrip strength. SGA, TST, MAC and HGS were significantly associated with CTP whereas no any statistically significant association was found between Child-Pugh and MAMC. There was statistically significant difference among the MELD Na means among SGA and HGS classes. The mean MELD Na scores did not significantly differ between among the TST, MAC and MAMC classes. The early diagnosis of the nutritional state and the treatment of malnutrition in cirrhotic patients can contribute to a reduction in the frequency and/or severity of these complications. SGA, TST, MAC and HGS are the non-invasive and easy methods of nutritional assessment of cirrhotic patients to use in regular clinical practice at bed side.

Assessment of Severity of Liver Cirrhosis and Nutritional status of Cirrhotic patients in Tribhuvan University Teaching Hospital, Kathmandu

Assessment of Severity of Liver Cirrhosis and Nutritional status of Cirrhotic patients in Tribhuvan University Teaching Hospital, Kathmandu

Assessment of nutritional status of the cirrhotic patients on enteral and parenteral feeding

Cirrhosis is an irreversible disease that replaces healthy tissues with scar tissues. According to the Pakistan Medical Research Council's national general population survey (2008-2014), the ratio of cirrhosis was 4.8% among the population. To assess the nutritional status of cirrhotic patients on enteral and parenteral nutrition and to assess the degree of malnutrition among cirrhotic patients. A cross-sectional study was conducted at Shalamar and Shiekh Zayed Hospitals of Lahore from January-April 2017. The convenient sampling technique was used. Inclusion criteria were the patients with decompensated liver cirrhosis, whereas compensated patients were excluded from the study. Data were collected through the patient's file, nurse's, and dietitian's notes. The nutritional status of participants was assessed based on socio-demographic characteristics, anthropometric measurements, biochemical assessment, clinical signs, and dietary recall. Variables were categorized and compared to observe the level of significance in enteral and parenteral nutrition. SPSS version 22 was used to analyze data. Patients on parenteral nutrition had a higher ratio of malnutrition with a significant Child-Pugh score-61.8% of patients belonged to Class C and 35.3% Class B, while in enteral support, 7.3% belonged to Class C and 43.9% patients belonged to Class B (p-value = 0.000). There was a definite relationship observed in the route of intake and malnutrition among cirrhotic patients. Enteral route of nutrition is an effective and the safest way to provide appropriate nutrients according to the patient's demands.

The effect of nutritional education and continuous monitoring on clinical symptoms, knowledge, and quality of life in patients with cirrhosis.

In this study, we aimed to evaluate the effectiveness of an educational intervention in patients with liver cirrhosis. Liver cirrhosis is end stage of liver diseases with many complications that affects quality of life and nutritional status in cirrhotic patients. Today, educational intervention and nutritional counseling is a key factor for preventing disease process and improving quality of life in patients with chronic diseases. This quasi-experimental, non-randomized, pre and post intervention were conducted as a pilot study on cirrhotic patients. Educational intervention and nutritional counseling were performed in clinical visits and via guide booklet. Chronic liver disease questionnaire (CLDQ) and knowledge questionnaire were used to assess patients' quality of life and knowledge. Blood samples were taken before and after intervention for assessment of laboratory outcomes. One hundred and seven patients referred to Research Center for enrolling in the trial. Twenty-eight did not meet inclusion criteria and seven patients were excluded from the study for lack of proper follow-up. Final analyses were done on 72 patients. Quality of life and knowledge of cirrhotic patients improved significantly after educational intervention (P < 0.0001). Biochemical characteristics were not changed significantly. Ascites and edema were improved significantly (P = 0.005 and P = 0.002, respectively). There was significant difference before and after intervention in the days of hospitalization (P = 0.001). We concluded a simple educational intervention and continuous monitoring for 6 months can affect clinical outcomes, quality of life, hospital admissions days, and knowledge of patients with cirrhosis.

Nutritional assessment of cirrhotic patients with variable severity

Introduction Malnutrition presents in more than half of cirrhotic patients. It is varied from 20% in compensated liver disease to 80% in decompensated liver disease. This study aimed at assessing the frequency of malnutrition and relation between the malnutrition and degree of liver severity. Patients and methods This study was carried out in Tropical Medicine and Gastroenterology Department at El-Rajhy Hospital in Assiut University, Egypt, from December 2015 to December 2016 on 101 patients diagnosed with liver cirrhosis. Based on their medical profile, the liver disease severity was determined by Child–Pugh, model for end-stage liver disease, and model for end-stage liver disease sodium scores, then nutritional status of the patients was assessed by different methods including anthropometric diameters (BMI, triceps skinfold thickness, mid-arm circumference, and mid-arm muscle circumference), body composition analysis, subjective global assessment, creatinine–height index, prognostic nutritional index (PNI), and controlling nutritional status (CONUT), and finally, we assessed the relation between the nutritional status and the severity of liver disease. Results The frequency of malnutrition among the studied patients varied from 25.7% by BMI to 98% by PNI and CONUT. There was difference in degree of malnutrition between the different groups of liver disease; however, this variation was not significant when anthropometric measures and body composition analysis were used but was statistically significant when subjective global assessment, creatinine–height index, PNI, and CONUT were used. Conclusion The nutritional status of cirrhotic patients is an important tool, together with Child and model for end-stage liver disease scores, for the prediction of prognosis of such patients. All the nutritional assessment tools are needed together with no substitution of one method by another for precise assessment of malnutrition among cirrhotic patients.

Validity of different nutritional assessment modalities as indicators of nutritional status in cirrhotic patients

Validity of different nutritional assessment modalities as indicators of nutritional status in cirrhotic patients

The Improvement of Nutritional Status of Cirrhotic Patients After Transjugular Intrahepatic Portosysthemic Shunt is Associated With the Amelioration of Cognitive Impairment

The Improvement of Nutritional Status of Cirrhotic Patients After Transjugular Intrahepatic Portosysthemic Shunt is Associated With the Amelioration of Cognitive Impairment

A Comprehensive Review of Bioelectrical Impedance Analysis and Other Methods in the Assessment of Nutritional Status in Patients with Liver Cirrhosis.

It is assumed that approximately 24–66% of patients with liver cirrhosis develop malnutrition. Numerous pathological processes lead to serious disorders of nutritional status in this group of patients. Malnutrition in the course of liver cirrhosis is associated with increased morbidity, complications, and low quality of life. Under these conditions, detection of malnutrition is of crucial importance. This review explores the complex mechanisms that lead to malnutrition in the course of liver cirrhosis and focuses on methods used in the assessment of nutritional status in cirrhotic patients. Among others, the role of bioelectrical impedance is highlighted. This noninvasive tool is promising and quite an accurate method of estimating body composition.

English

Assessment of nutritional status in cirrhotic patients is very difficult, and there is no gold-standard method used for nutritional evaluation of these patients. The study aims to assess the role of creatinine height index in evaluation of nutritional status of patients with liver cirrhosis, and to compare its results with different ordinary methods used for nutritional assessment. The study was cross sectional observational study, carried out at El-Rajhi Liver Hospital and internal medicine department in Assiut University on 103 patients with liver cirrhosis after obtaining their informed consent form May to September 2015. 24 h urine collection was obtained from all patients, then measurement of their urine creatinine was done, after that, creatinine height index (CHI) was calculated for every patient, furthermore, All patients did the followings investigations: Serum albumin, Anthropometric measurements, Subjective Global Assessment. Then its results were compared with their CHI. According to CHI, malnutrition was present in 89.2% of patients: 11 patients (11.8%) were mildly malnourished, 38 (40.8%) were moderately malnourished and 35 (36.6%) were severely malnourished, Subjective Global Assessment detects malnutrition in 92.2% of patients. Furthermore, 87.4% of the patients were malnourished according to Mid Arm Muscle Circumference while 86.4% of them were malnourished according to Triceps Skin Fold Thickness. Mean value of CHI was decreased markedly from 86.1, 64.5 to 39.1% in Child score A, B and C respectively (P value= 0.000). CHI is a good predictor of muscle mass in patients with liver cirrhosis. Key words: CHI, nutritional status, liver, cirrhosis, assessment.

Assessment of Malnutrition in Cirrhotic Patients

Malnutrition is a common but frequently overlooked problem among patients with cirrhosis of liver. Malnourished cirrhotic patients have a higher rate of complications and an overall increased mortality. Identifying these patients is of great clinical importance. This study was carried out to assess nutritional status of cirrhotic patients to identify those who are malnourished and to see the relationship between severity of liver disease and malnutrition. 105 patients were selected by purposive type sampling. Nutritional status was assessed by 3 anthropometric assessment tools- body mass index (BMI), mid upper arm muscle circumference (MAMC) and triceps skin fold thickness (TST). Severity of liver disease was assessed by Child-Pugh (CP) score. Severe malnutrition was defined as MAMC and TST &lt;5th percentile, calculated from standard tables, and as BMI &lt;16. Among 105 patients 18, 49 and 38 were of Child-Pugh group (CP group) A, B and C respectively. Anthropometric assessment revealed that, when assessed by MAMC 63% of the study population were severely malnourished. Based on MAMC, severe malnutrition was present in 39%, 63% and 73% patients in CP group A, B and C, respectively (P&lt;0.05). So, percentage of severely malnourished patient increased with the increase in severity of liver disease. Based on TST, 28%, 34% and 50% patients were severely malnourished in CP-A, CP-B and in CP-C (p&gt;0.05) respectively which showed a trend similar to that by MAMC. Whereas, based on BMI, 0%, 8% and 2% patients were severely malnourished respectively (p&gt;0.05). It showed a decrease in the percentage of severely malnourished patient in CP group C than in CP group B. In this study, nutritional assessment by TST and MAMC revealed that severe malnutrition was common in our study population and assessment by MAMC showed a statistically significant association of severity of liver disease with severe malnutrition.Bangladesh Journal of Medical Science Vol.15(2) 2016 p.189-194

Malnutrition is related to a higher frequency of serious complications in patients with cirrhosis

IntroductionPatients with cirrhosis are at risk of malnutrition and this has been recognized as a predictor of morbidity and mortality. The aim of this study was to compare the frequency of serious complications (variceal bleeding, ascites, hepatic encephalopathy and infections) between cirrhotic patients with and without malnutrition. Subjects and methodsAn observational, analytic, cross-sectional study. The nutritional status of cirrhotic patients was evaluated according to Subjective Global Assessment (SGA). Characteristics of cirrhotic patients with and without malnutrition were compared. Results103 cirrhotic patients were included, 58 (56.3%) were women; the media of age was 55±12.2 years. According to SGA, 45 patients (43.7%) were classified as well-nourished, and 58 (56.3%) as malnourished. The development of serious complications was related to nutritional status. Malnourished patients had higher frequency of development of ascites (67.2% vs. 42.2%, P=0.01, OR=2.8; 95% CI: 1.3–6.3) and infections (21.4% vs. 6.7%, P=0.03, OR=4.5; 95% CI: 1.2–16.6). ConclusionsThe presence of serious complications, such as, ascites and development of bacterial and fungal infections, was more frequent between cirrhotic patients with malnutrition than in those well-nourished.

Effect of nutrition on prognosis of Egyptian cirrhotic patients

Malnutrition is a common complication of end-stage liver disease, by far the easiest methods to differentiate compensated and uncompensated liver cirrhosis are the Child–Pugh and MELD score. These methods have omitted under nutrition from their scoring. Present study is aimed to study the effect of malnutrition among Egyptian cirrhotic patients on the prognosis and mortality. 300 Egyptian cirrhotic patients, laboratory and nutritional assessment were done according to RFH-SGA, measurement of BMI, TST, and MAMC. Each patient was assigned a Child and MELD score and all patients were followed up for six months. 49 patients (16.3%) died throughout the follow up. 57(19%) were severely malnourished. 134 (44.66%) and109 (36.33%) were well nourished and moderately malnourished, respectively. 63.4% of non-survivors were malnourished (p=0.001). A higher MELD score in non-survivors (29.8) than that of survivors (21.7) (P=0.007). Increase the TST (triceps skinfold thickness) in survivors (10.1mm i.e. less than 50 th percentile) than in non-survivors (5.9mm i.e. less than 5 th percentile) (P=0.003). The MAMC (midarm muscle circumference) was 24.5cm (i.e. 10 th percentile) and 19.4cm (i.e. less than 5 th percentile) in survivors and non-survivors, respectively (P=0.002). The nutritional status of cirrhotic patients is an important tool, together with MELD and Child score, to predict the prognosis of such patients and the severity of malnutrition is associated with higher mortality, early referral of cirrhotic patients with bad nutritional status for transplantation is recommended.

Nutritional assessment in cirrhotic patients with hepatic encephalopathy.

Hepatic encephalopathy (HE) is one of the worst complications of liver disease and can be greatly influenced by nutritional status. Ammonia metabolism, inflammation and muscle wasting are relevant processes in HE pathophysiology. Malnutrition worsens the prognosis in HE, requiring early assessment of nutritional status of these patients. Body composition changes induced by liver disease and limitations superimposed by HE hamper the proper accomplishment of exams in this population, but evidence is growing that assessment of muscle mass and muscle function is mandatory due to the role of skeletal muscles in ammonia metabolism. In this review, we present the pathophysiological aspects involved in HE to support further discussion about advantages and drawbacks of some methods for evaluating the nutritional status of cirrhotic patients with HE, focusing on body composition.

Is the Phase Angle, a Prognostic Indicator for Nutritional Status in Cirrhotic Patients?

Background & Aim: The phase angle value, obtained by bioelectrical impedance analysis, is an important prognostic indicator in several clinical conditions. This study aimed to compare the performance of the standardized phase angle with that of Child-Pugh score, a well-known prognostic indicator of chronic liver disease. Methods: A cross-sectional study was conducted with cirrhotic patients. Bioelectrical impedance analysis was performed, and the standardized phase angle was calculated. Low standardized phase angle was defined as a value below -1.65. The significance level was set at 5%. Results: Of 195 participants, 59% were male. Mean age was 55.9 ± 10.8 years; 59% of patients were classified as Child-Pugh class A, 22.6% as class B, and 18.5% as class C. The Phase Angle average was 5.79 (±1, 20) with z score average -0.75 (±1, 61). 76.4% of the population studied showed Phase Angle indicative of good prognosis. Conclusions: The standardized phase angle was correlated with the Child-Pugh score and can therefore be considered a reliable prognostic indicator of nutritional status in cirrhotic patients.

Nutritional Status Assessment in Cirrhotic Patients after Protein Supplementation

Background. Protein supplementation has been shown to be effective for the treatment of malnourished patients with liver cirrhosis. The parameters used to assess nutritional improvement in cirrhotic patients for such treatment are important. Objective. To evaluate the parameters for assessment of nutritional status in patients with liver cirrhosis after protein supplementation. Material and Method. A cross-sectional, prospective clinical trial with 22 cirrhotic patients was performed. Data from anthropometry, bioelectrical impedance, subjective global assessment (SGA), and visceral protein were gathered and analyzed to assess nutritional improvement after protein supplementation. Results. Twenty-two cirrhotic patients (mean age 52.9 ± 12.8 years; 54.5% male; 63.6% alcoholic cirrhosis; 63.6% Child-Pugh C) were recruited. After protein supplementation, a significant improvement was demonstrated in the SGA class A from 10 patients (45.5%) to 16 (72.7%) and 18 (81.8%) at the 4th and 8th weeks, respectively. Body weight, body mass index, and lean muscle mass were significantly increased from baseline at the 8th week. No significant change in other nutritional parameters was observed. Conclusions. The SGA and lean muscle mass were significant parameters in order to assess nutritional status in cirrhotic patients after protein supplementation.

Nutritional status and prognosis in cirrhotic patients

Malnutrition is commonly associated with chronic liver disease. The presence of protein-calorie malnutrition has been shown to be associated with increased short- and long-term mortality in patients with acute and chronic liver disease. We undertook this study to assess the prognostic value of nutritional status in predicting survival in cirrhotic patients. The aim of our study was to determine whether assessment of nutritional status using the RFH-SGA score adds significantly to CP (Child-Pugh) and MELD scores in predicting patient prognosis and survival in cirrhotic patients. Diagnosed cases of cirrhosis were enrolled and their nutritional assessment was done using the RFH-SGA score. All patients were followed up for a period of 6 months. The mortality rates in the various groups were compared with respect to their nutritional status. Multivariate analysis was used to determine the factors associated with mortality. A total of 73 cirrhotic patients were taken up for this study. Of these, 23 patients (31.5%) were well nourished, 21 (28.8%) had mild to moderate malnourishment and 29 (39.7%) were severely malnourished. Multivariate analyses of various parameters identified poor nutritional status, increased CP grade, increased creatinine, lower sodium levels and longer prothrombin time as being independently associated with poorer survival. RFH-SGA is a simple and inexpensive tool for assessing the nutritional status in cirrhotic patients and can reliably predict their disease prognosis and survival.

Effects of branched‐chain amino acid‐enriched nutrient for patients with hepatocellular carcinoma following radiofrequency ablation: A one‐year prospective trial

This prospective control study examined whether supplementation with branched-chain amino acid (BCAA)-enriched nutrients can help maintain and improve residual liver function and nutritional status in cirrhotic patients with hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA). Subjects were 49 patients with hepatitis C-related HCC who underwent RFA. Two groups were formed: BCAA group (BCAA-enriched nutrient, aminoleban EN) and controls (standard diet only). Event-free survival rate, liver function tests, and Short Form (SF)-8 scores were evaluated in both groups before and one year after RFA. Energy metabolism using indirect calorimetry was measured before and after 3 months. Complete data were obtained from 35 patients (BCAA group, n = 20; controls, n = 15). Six events (death, recurrence of HCC, rupture of esophageal varices and liver failure) occurred during the observation period, but frequencies of these events did not differ between groups. Event-free survival rate tended to be higher in the BCA group than in controls. Among the parameters of liver function, serum albumin level was only significantly increased over 6 months, and remained at similar values for one year (P < 0.05). SF-8 scores for general health, physical functioning, and social functioning were significantly elevated in the BCAA group (P < 0.05). Non-protein respiratory quotient was significantly improved in the BCAA group (P < 0.01). Supplementation with BCAA-enriched nutrients for one year in cirrhotic patients with HCC after RFA therapy can perform safety and improve both nutritional state and quality of life.

Heating improves poor compliance with branched chain amino acid-rich supplementation in patients with liver cirrhosis: A before-after pilot study

Although branched chain amino acid (BCAA) supplementation improves malnutrition in cirrhotic patients, patient compliance with the administration of BCAA-rich supplements is poor due to their bitter taste. Since temperature is an important factor affecting taste, we examined the effect of heating on the stability of BCAAs and on the compliance of patients with liver cirrhosis with BCAA-rich supplement administration. A thermal denaturation test was first conducted, in which the BCAA-rich supplement Aminoleban® EN was heated to 37, 60, or 80°C for 30 or 60 min. The concentration of three amino acids, L-valine, L-leucine and L-isoleucine, was subsequently measured. The nutritional status of the cirrhotic patients was also evaluted. Patients presenting liver failure with a Child-Pugh class of A (n=2), B (n=2) or C (n=2) were hospitalized at Kurume University Hospital. Six patients with liver cirrhosis (HCV, n=3; HBV, n=1; alcohol, n=2) were enrolled. Venous blood samples were drawn in the morning after a 12-h overnight fast. The BCAA-rich supplement was administered to patients at room temperature (25°C) or heat loaded at 60°C for 10 min, with the temperature maintained above 45°C. Each patient was interviewed by a nationally registered dietitian regarding food consumption and intake of the BCAA-rich supplement immediately after each meal. Nutritional status was evaluated according to serum albumin levels, blood hemoglobin, prothrombin time and total lymphocyte count. No significant decrease was noted in valine, leucine or isoleucine levels following the heating of the BCAAs to 80°C. The caloric intake of the BCAA-rich supplement was significantly higher with administration after heating to 60°C, compared to caloric intake with administration at 25°C. In addition, heating of the BCAA-rich supplement significantly increased blood lymphocyte counts. In conclusion, heating did not affect the stability of the BCAAs, and may improve compliance with BCAA-rich supplement administration. As a result, the nutritional status of cirrhotic patients may be improved.