Nutritional status and the performance of multiple bedside tools for nutrition assessment among patients waiting for liver transplantation: A Canadian experience

Nutritional assessment of patients with liver cirrhosis in the outpatient setting: A narrative review

Malnutrition is common in liver cirrhosis and is associated with increased rates of complications, hospitalization, and mortality. There are no consensus guidelines for malnutrition assessment in liver cirrhosis and a large number of clinicians do not routinely assess for malnutrition in patients with liver cirrhosis. This review explores the tools available for assessment of malnutrition in patients with liver cirrhosis, including nutritional screening protocols, anthropometric tools, biochemical tools, techniques analyzing body composition and functional assessments. We evaluate these tools and offer recommendations regarding their suitability for outpatient settings. In this review, we recommend the Royal Free Hospital-Nutritional Prioritising Tool for identifying patients at risk of malnutrition. Additionally, we recommend the use of the anthropometric tools Triceps Skinfold Thickness for females and Mid-Arm Muscle Circumference for males, due to differing patterns of muscle and fat malnutrition. Complementing this Bioelectrical Impedance Analysis can be utilized to assess body composition for the diagnosis of malnutrition. Biochemical markers have thus far failed to show a correlation with malnutrition. While hand grip strength is useful for detecting sarcopenia, a common complication of malnutrition, further evidence is required to validate its correlation with malnutrition.

Screening and assessment of malnutrition in patients with liver cirrhosis

The development and advancement of malnutrition is associated not only with the progression of hepatic dysfunction, but also with cirrhosis-related complications. However, the prevalence of malnutrition reported in different studies varies widely due to differences in diagnostic methods and patient investigation settings. Therefore, we need to identify malnourished patients promptly and accurately. The purpose of this review was to compare the validity and reliability of nutritional screening tools and to select the most appropriate nutritional risk screening for patients with cirrhosis. We compared nutritional risk screening tools such as the Nutritional Risk Screening 2002 (NRS-2002), Malnutrition Universal Screening Tool (MUST), Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) and Liver Disease Undernutrition Screening Tool (LDUST). Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) is more feasible to screen cirrhotic patients for nutritional risk, and is highly reproducible, considering the impact of sodium and water retention; so it is practical to screen cirrhotic patients via RFH-NPT for nutritional risk, subsequently, to evaluate the nutritional status of patients with nutritional risk via the Global Leadership Initiative on Malnutrition (GLIM) diagnostic criteria. L3-SMI (third lumbar-skeletal muscle index) can accurately define sarcopenia in cirrhotic patients and also be used for clinical nutritional status assessment.

Effect of a 12-week nutritional intervention in the food intake of patients on the waiting list for liver transplantation: A secondary analysis of a randomized controlled trial

BACKGROUND

Inadequate food intake contributes to malnutrition in patients with cirrhosis on the waiting list for liver transplantation (LTx).

OBJECTIVE

To evaluate food intake during 12 weeks of nutritional follow-up and assess factors independently associated with the difference between energy and protein intake in LTx patients.

METHODS

A secondary analysis of data from a randomized controlled trial that evaluated the effects of Beta-Hydroxy-Beta-Methylbutyrate (HMB) supplementation and nutritional intervention in patients on a liver transplant waiting list. Dietary guidelines for patients with cirrhosis were used to prescribe the nutritional plan (35 kcal/kg; 1.5 g/kg dry weight for protein) and to evaluate the nutritional goals (30 kcal/kg; 1.2 g/kg dry weight for protein; late evening snack) and nutritional counseling dietary follow-ups were performed in each evaluation. Food intake was assessed in six moments: Baseline, week 0 (W0), week 2 (W2), week 4 (W4), week 8 (W8), and week 12 (W12).

RESULTS

Forty-seven patients (55.0 ± 10.6y; 72.3% male) were evaluated. Only 25.5% (n = 12) of patients achieved nutritional goals at the end of the study. The mean energy intake at Baseline was 1782 ± 784 kcal (27.6 ± 13.2 kcal/kg) without difference between moments. The protein intake increased between W0 [63.4 ± 29.8g; 0.8(0.2-2.2 g/kg)] and W8 [72.0 ± 28.0g; 1.0(0.4-2.6 g/kg); p = 0.03; p = 0.03, respectively]. The consumption of cholesterol, calcium, phosphorus, magnesium, iron, and niacin increased (p < 0.05), as well as the consumption of legumes; roots and tubers; dairy; and meat, poultry and fish groups through time (p < 0.05). The percentage of patients that consumed a late evening snack rised from 40.4% (Baseline) to 76.6% (W8) (p < 0.001). The presence of ascites, nourished patients, frailty index classification, short physical performance battery score, systemic symptoms, and emotional function in the Quality of Life Test were independently associated with the energy intake difference between W12 and Baseline (p < 0.05). Diabetes mellitus, patients with moderately malnourishment, poor performance, fatigue, systemic symptoms, and emotional function in the Quality of Life Test were independently associated with the difference in protein intake between W12 and Baseline (p < 0.05).

CONCLUSION

Patients on the liver transplant waiting list showed slight food intake improvement during the follow-up, but few met nutritional guidelines. Various clinical and nutritional factors independently affected energy and protein intake from W12 to Baseline.

Assessment of the Risk of Malnutrition or Frailty Among Patients Undergoing Liver Transplantation: A Hospital-Based Prospective Study

Objective

We aimed to explore the status of nutritional and frailty in patients undergoing liver transplantation and the associated influencing factors.

Methods

We conducted a follow-up analysis of 44 patients who underwent liver transplantation between 2021 and 2022. We followed up and recorded the nutritional status and risk of weakness at different time-points (days 1, 2, 3, 6, 9, and 12) postoperatively. Patient information regarding demographics, physical examination, medical history, and perioperative blood tests were collected. Binary logistic regression was applied to identify risk factors for weakness after liver transplantation.

Results

The cohort comprised 44 liver transplant recipients, with a mean age of 47.66 years (standard deviation=9.49 years). Initial analysis revealed that, compared to the group without nutritional risks, the group with nutritional risks displayed elevated age and preoperative blood ammonia levels one week post-surgery. Moreover, this group had reduced levels of albumin and total bile acid preoperatively. Patients with preoperative nutritional risks were also prone to similar risks 2 weeks postoperatively. Further, a correlation was observed between preoperative pulmonary infections and increased frailty risk 6 days postoperatively. At both 9 and 12 days postoperatively, patients with frailty risk exhibited higher preoperative white blood cell counts and ammonia levels than those without. Multivariable analysis, controlling for confounding factors, indicated a significant association between preoperative nutritional status and nutritional risk 2 weeks postoperatively, as well as a link between preoperative white blood cell count and frailty risk at 12 days postoperatively.

Conclusion

There was a significant correlation between preoperative nutritional status and nutritional risk 2 weeks after liver transplantation, and preoperative white blood cell count was an independent risk factor for weakness 12 days postoperatively. Preoperative nutritional management for patients could potentially mitigate the likelihood of adverse clinical outcomes.

Impact of Geriatric Nutritional Risk Index After Initial Hepatectomy for Hepatocellular Carcinoma: a Retrospective Cohort Study with the Hiroshima Surgical Study Group of Clinical Oncology (HiSCO)

INTRODUCTION

The importance of a nutrition scoring system, including the geriatric nutritional risk index (GNRI), was reported as an objective tool widely used to assess nutritional status in patients with inflammatory disease, chronic heart failure, and chronic liver disease. However, studies on the relationship between GNRI and the prognosis in patients who have undergone initial hepatectomy have been limited. Thus, we conducted a multi-institutional cohort study to clarify the relationship between GNRI and long-term outcomes for hepatocellular carcinoma (HCC) patients after such a procedure.

METHODS

Data from 1,494 patients who underwent initial hepatectomy for HCC between 2009 and 2018 was retrospectively collected from a multi-institutional database. The patients were divided into two groups according to GNRI grade (cutoff: 92), and their clinicopathological characteristics and long-term results were compared.

RESULTS

Of the 1,494 patients, the low-risk group (≥ 92; N = 1,270) was defined as having a normal nutritional status. Meanwhile, low GNRI (< 92; N = 224) were divided into malnutrition as the high-risk group. Multivariate analysis identified seven prognostic factors of poor overall survival (higher tumor markers; α-fetoprotein (AFP) and des-γ-carboxy protein [DCP], higher ICG-R15 levels, larger tumor size, multiple tumors, vascular invasion, and lower GNRI and eight prognostic factors of high recurrence (HCV antibody positive, higher ICG-R15 levels, higher tumor markers such as AFP and DCP, greater bleeding, multiple tumors, vascular invasion, and lower GNRI).

CONCLUSIONS

In patients with HCC, preoperative GNRI predicts poorer overall survival and high recurrence.

Predicting dry weight in patients with cirrhotic ascites undergoing large-volume paracentesis

BACKGROUND & AIMS

Ascites impairs the correct diagnosis and nutritional management in patients with cirrhosis, because the body weight, which is needed for nutritional assessment and calculation of nutritional needs, is overestimated. To adjust the weight in patients with ascites, dietetic guidances indicate substracting 2.2-14 kg or 5-15% of the measured body weight according to the degree of ascites, however, there is a lack of evidence to substantiate these values. The aim of this study was to develop new prediction equations to estimate the dry weight, comparing them with the currently used weight adjustments in patients with refractory cirrhotic ascites.

METHODS

Cross-sectional study, that included patients with decompensated cirrhosis undergoing large-volume paracentesis. Patients were submitted to nutritional risk screening, nutritional assessment, and anthropometric measurements that included body weight, abdominal circumference (both measured before and after paracentesis) height, and upper mid-arm circumference. The volume of ascitic fluid drained was also registered. For the predictions of dry weight, linear regression models were performed using as predictor variables: height, pre-paracentesis weight, pre-paracentesis abdominal circumference, or mid-upper arm circumference, and as response variable: post-paracentesis weight. The capacity of these models to predict the post-paracentesis weight was evaluated by comparing it with the currently used predictions through the intraclass correlation coefficient (ICC) and the mean squared error (MSE).

RESULTS

Nineteen patients were included, 15 male, and 18 with high nutritional risk and malnutrition. The difference between post-paracentesis weight and pre-paracentesis weight was -5.0 (-3.6 to -9.9) kg, similar to ascitic fluid volume drained. Two equations were developed to predict post-paracentesis weight. ICC values showed that both prediction equations were strongly correlated (r > 0.94) with post-paracentesis weight. Our models also showed lower MSEs (<17.97), compared with the current predictions (MSEs <64.19, when the pre-paracentesis weight is adjusted from absolute values and MSEs <33.24 when adjusted from percentage values), indicating a more accurate prediction.

CONCLUSION

The predictive equations from this study may be better options for dry weight estimation in patients with refractory cirrhotic ascites since they showed higher reliability compared to the currently used weight adjustment. External validation in a larger sample is still needed to confirm the clinical applicability of these equations.

Measurement of mid-arm circumference as a starting point for nutritional assessment of patients with decompensated cirrhosis: A prospective cohort study

BACKGROUND

The mid-arm circumference (MAC) is an accessible, quick, and inexpensive measurement, which can be performed at the bedside only with a measuring tape. In this sense, the present study aims to suggest MAC cut-off values to assess the nutritional status and its association with mortality of hospitalised patients with decompensated cirrhosis.

METHODS

A prospective cohort study was performed with decompensated cirrhotic patients. Nutritional status was assessed by MAC and Subjective Global Assessment (SGA). Considering the SGA as the reference standard and based on receiver operating characteristic curve analysis, the MAC cut-off values with the best sensitivity and specificity were selected. Predictors of mortality were identified using multivariate analysis.

RESULTS

The study included 100 patients with a mean ± SD age of 60.1 ± 10.3 years. The median follow-up time was 11.2 months and overall mortality was 60%. Considering malnutrition assessed by SGA as the reference standard, the area under the curve of MAC for women and men was 0.947 (95% confidence interval [CI] = 0.878-1.000) and 0.813 (95% CI = 0.694-0.932). The MAC cut-off values of ≤ 28 cm for women and ≤ 30 cm for men reached a sensitivity and specificity of 85.5% and 71%, respectively. According to multivariate analysis, a low MAC was significantly associated with mortality (hazard ratio = 2.41; 95% CI = 1.20-4.84).

CONCLUSIONS

The MAC cut-off values had satisfactory accuracy for men and women in predicting malnutrition. Additionally, a low MAC was an independent predictor of mortality. Thus, these MAC cut-off values can be used as the first step of nutritional assessment to prioritise patients who require more detailed assessment.

Protein Catabolism and the Dysregulation of Energy Intake-Related Hormones May Play a Major Role in the Worsening of Malnutrition in Hospitalized Cirrhotic Patients

Malnutrition in cirrhotic patients is extremely common and has a multifactorial aetiology, whose constitutive elements have not been completely elucidated yet. Protein depletion is particularly important and an imbalance of hormones regulating hunger and satiety may be an important additive factor. The diagnosis and treatment of malnutrition are extremely important since malnutrition is associated with higher complication rates and mortality. Our observational study aimed to study protein status and energy intake-related hormone levels in a cohort of hospitalized cirrhotic patients. We enrolled 50 hospitalized and clinically stable cirrhotic patients and assessed their nutritional status with anthropometric measurements and nitrogen balance. In a subgroup of 16 patients and 10 healthy controls, circulating ghrelin and leptin levels were studied. We observed that 60% of our patients were malnourished on the basis of the mid-arm muscle circumference values; the recorded daily protein intake was tendentially insufficient (mean protein intake of 0.7 ± 0.5 g protein/kg vs. recommended intake of 1.2–1.5 g of protein/kg/die). Cirrhotic patients had lower circulating levels of both ghrelin and leptin compared to healthy controls. In conclusion, hospitalized cirrhotic patients face a catabolic state and an imbalance in hormones regulating food intake and satiety, and these elements may play a major role in the genesis and/or the worsening of malnutrition.

Comparison of Different Nutritional Assessment Tools in Detecting Malnutrition and Sarcopenia among Cirrhotic Patients

Malnutrition and sarcopenia are common complications of liver cirrhosis. This study compares the performance of different nutritional assessment techniques in detecting malnourished patients. Data from 156 patients with liver cirrhosis were collected. We assessed the nutritional status of these patients according to: Subjective Global Assessment (SGA); Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT), skinfold thickness (TSF), mid-upper arm circumference (MUAC), mid-upper arm muscle circumference (MUMC), handgrip strength (HGS), body mass index (BMI), and skeletal muscle index (SMI) evaluated by Contrast-Enhanced Computed Tomography (CT). According to EWGSOP2 criteria, combining low HGS with low SMI, the prevalence of malnutrition/sarcopenia was 60.2%. RFH-NPT, MUAC, MAMC, and HGS were excellent tests for detecting malnourished patients. Combining RFH-NPT with MUAC or MUMC increased diagnosis accuracy, AUC = 0.89, p < 0.0001. Age, Child-Pugh class C, albumin level, vitamin D deficiency, male gender, and alcoholic etiology were significantly associated with malnutrition. In conclusion, the prevalence of malnutrition among patients with cirrhosis was relatively high. Our study highlights the potential use of a simpler and inexpensive alternative that can be used as a valuable tool in daily practice, the combination between RFH-NPT and MUAC.

Optimizing Inpatient Nutrition Care of Adult Patients with Inflammatory Bowel Disease in the 21st Century

Malnutrition is highly prevalent in inflammatory bowel disease (IBD) patients and disproportionately affects those admitted to hospital. Malnutrition is a risk factor for many complications in IBD, including prolonged hospitalization, infection, greater need for surgery, development of venous thromboembolism, post-operative complications, and mortality. Early screening for malnutrition and prompt nutrition intervention if indicated has been shown to prevent or mitigate many of these outlined risk factors. There are many causes of malnutrition in IBD including reduced oral food intake, medications, active inflammation, and prior surgical resections. Hospitalization can further compound pre-existing malnutrition through inappropriate diet restrictions, nil per os (NPO) for endoscopy and imaging, or partial bowel obstruction, resulting in "post-hospital syndrome" after discharge and readmission. The aim of this article is to inform clinicians of the prevalence and consequences of malnutrition in IBD, as well as available screening and assessment tools for diagnosis, and to offer an organized approach to the nutritional care of hospitalized adult IBD patients.

Nutritional assessment and factors affecting dietary intake in patients with cirrhosis: A single-center observational study

OBJECTIVES

Malnutrition is predictor of morbidity and mortality in patients with cirrhosis. We investigated prevalence of malnutrition and factors affecting dietary intake in patients with cirrhosis.

METHODS

Single-center cross-sectional observational study. A total of 251 patients with cirrhosis underwent dietary and nutritional assessment by subjective global assessment (SGA) and anthropometric measurement (dry body mass index, midarm circumference, midarm muscle circumference, triceps skinfold thickness, handgrip strength). Dietary intake was assessed in terms of total calories and protein intake, percentage of recommended intake, and per kilogram body weight per day. Factors influencing dietary intake were also assessed.

RESULTS

Of 251 patients 199 (79%) were male and 52 (21%) were female (mean age, 51 ± 14 y, Child's A:B:C: 83:116:52). In SGA analysis 87 (35%) were well nourished (SGA-A), 106 (42%) were moderately nourished (SGA-B), and 58 (23%) were severely malnourished (SGA-C). Patients with Child's C score were severely malnourished compared with patients with Child's B and A scores. Midarm circumference, midarm muscle circumference, triceps skinfold thickness, and handgrip strength were significantly higher in SGA-A than SGA-B and SGA-C. Patients in SGA-A (1939 ± 479 kcal/d) consumed significantly higher calories than SGA-B (1494 ± 216 kcal/d) and SGA-C (1321 ± 213 kcal/d). Percentage of recommended calories intake (SGA-A [76%], SGA-B [61%], SGA-C [59%], P = 0.001) and calories/kg/d is also higher in SGA-A than SGA-B and SGA-C. The results with protein intake were similar (SGA-A [61 ± 14 gm/d], SGA-B [56 ± 7 gm/d], SGA-C [51 ± 9 gm/d], P = 0.001). Protein intake in g/kg/d is significantly lower in SGA-C (0.76 ± 0.22) than SGA-B (0.85 ± 0.2) and SGA-A (0.93 ± 0.2). A total of 61% patients were vegetarian, and 84% did not take evening snacks. Poor appetite (n = 68, 27%), early satiety (n = 75, 30%), abdominal fullness (n = 62, 25%), low-salt diet (n = 52, 21%), and social myth about diet 43(17%) were the common reasons for poor intake. Distension of abdomen, social myth about diet, and low sodium in diet were key factors affecting dietary intake in patients with cirrhosis and malnutrition.

CONCLUSIONS

Malnutrition seen in 65% of patients. Total calories and protein intake was significantly low compared with recommendation even in well-nourished patients. Distension of abdomen, social myth about diet, and low sodium in diet were key factors affecting dietary intake in patients with cirrhosis and malnutrition.

Nutritional Assessment and Malnutrition in Patients With Cirrhosis

We sought to determine the incidence and outcomes of malnutrition in patients with cirrhosis. We performed a retrospective chart review of 134 patients listed for liver transplant (LT) to assess the presence and degree of malnutrition identified by the Subjective Global Assessment score at the time of initial transplant evaluation, follow-up nutrition visits, and at the time of transplant. Number of admissions/readmissions to the hospital, reason for hospitalization(s), and length of stay were determined. Malnutrition was prevalent at initial nutrition visit (51.9%) and underdiagnosed. By the time of transplant, 61% of the patients were identified as malnourished. Most patients (52%) were awaiting LT for more than 180 days. The change in Subjective Global Assessment score after the initial nutrition assessment was statistically significant (p ≤ .007), with worsening malnutrition severity. Seventy-one patients (53%) required hospitalization while awaiting transplant, with a median hospital stay of 9 days. Nutrition expertise is required for prompt and accurate diagnosis of malnutrition in patients with cirrhosis. Nurses caring for patients with advanced liver disease are in a prime position to provide guidance to optimize patient outcomes.

Utility of the simplified measurements of muscle mass in patients with gastrointestinal and chronic liver diseases

Sarcopenia is an important prognostic factor in patients with gastrointestinal and chronic liver diseases. Computed tomography and bioelectrical impedance analysis are the gold standards for measuring skeletal muscle mass for the diagnosis of decreased muscle mass, but there are some institutions where BIA and CT cannot be carried out. We evaluated the utility of simplified methods for measuring muscle mass; the psoas muscle mass index (PMI) method, simple PMI method, and arm muscle area (AMA) method. This retrospective study included 331 patients with gastrointestinal diseases and 81 patients with chronic liver diseases who were admitted from June 2018 to December 2019 at Municipal Hospital of Kofu. The skeletal muscle mass was measured using the PMI via the volume analyzer SYNAPSE VINCENT ver3.0, simple PMI based on CT imaging, and AMA method. Positive correlations were found between muscle mass measured by PMI and simple PMI, PMI and AMA, and simple PMI and AMA in patients with gastrointestinal diseases (correlation coefficients = 0.76, 0.57, 0.47, respectively, p < 0.001). Positive correlations were observed between muscle mass measured by PMI and simple PMI, PMI and AMA, and simple PMI and AMA in chronic liver diseases (correlation coefficients = 0.77, 0.53, 0.45, respectively, p < 0.001). Measurement of muscle mass by the AMA method showed some correlation with the PMI method. Measurement of muscle mass by the simple PMI method showed correlation with the PMI method. These simplified methods can be alternative methods of evaluating muscle mass in patients with gastrointestinal and chronic liver disease.

Royal Free Hospital-Nutritional Prioritizing Tool improves the prediction of malnutrition risk outcomes in liver cirrhosis patients compared with Nutritional Risk Screening 2002

The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines recommend the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) to identify malnutrition risk in patients with liver disease. However, little is known about the application of the RFH-NPT to screen for the risk of malnutrition in China, where patients primarily suffer from hepatitis virus-related cirrhosis. A total of 155 cirrhosis patients without liver cancer or uncontrolled co-morbid illness were enrolled in this prospective study. We administered the Nutritional Risk Screening 2002 (NRS-2002), RFH-NPT, Malnutrition Universal Screening Tool (MUST) and Liver Disease Undernutrition Screening Tool (LDUST) to the patients within 24 h after admission and performed follow-up observations for 1·5 years. The RFH-NPT and NRS-2002 had higher sensitivities (64·8 and 52·4 %) and specificities (60 and 70 %) than the other tools with regard to screening for malnutrition risk in cirrhotic patients. The prevalence of nutritional risk was higher under the use of the RFH-NPT against the NRS-2002 (63 v. 51 %). The RFH-NPT tended more easily to detect malnutrition risk in patients with advanced Child–Pugh classes (B and C) and lower Model for End-stage Liver Disease scores (<15) compared with NRS-2002. RFH-NPT score was an independent predictive factor for mortality. Patients identified as being at high malnutrition risk with the RFH-NPT had a higher mortality rate than those at low risk; the same result was not obtained with the NRS-2002. Therefore, we suggest that using the RFH-NPT improves the ability of clinicians to predict malnutrition risk in patients with cirrhosis primarily caused by hepatitis virus infection at an earlier stage.

The Anthropometric Assessment With the Bioimpedance Method Is Associated With the Prognosis of Cirrhotic Patients

BACKGROUND/AIM

The bioimpedance analysis (BIA) can provide anthropometric data on patients. The aim of the study is to evaluate the clinical relevance of these automatically obtained values.

PATIENTS AND METHODS

We studied the arm circumference (AC) and arm muscle circumference (AMC) of 197 histologically proven cirrhotic patients. The BIA-based anthropometric data were compared to the manually measured data. In addition, we evaluated whether or not the BIA-based anthropometric data were associated with the prognosis of the patients.

RESULTS

The data of %AC and %AMC obtained using the two methods were well correlated (p<0.001) with relatively inconspicuous differences (approximately 6.0% for %AC and 16.0% for %AMC). The data of %AC and %AMC obtained from the BIA method were significantly associated with the prognosis of the patients.

CONCLUSION

The BIA-based anthropometric data were associated with the direct measurement data and related to the prognosis of cirrhotic patients.

The Analysis of Food Intake in Patients with Cirrhosis Waiting for Liver Transplantation: A Neglected Step in the Nutritional Assessment

Patients with cirrhosis waiting for liver transplantation (LT) frequently present a nutritional disorder, which represents an independent predictor of morbidity and mortality before and after transplantation. Thus, a proper assessment of the food intake by using different methods, such as food records, food frequency questionnaires, and 24 h recall, should be deemed an important step of the nutritional management of these patients. The available published studies indicate that the daily food intake is inadequate in the majority of waitlisted patients. These findings were confirmed by our experience, showing that the daily intake of total calories, proteins and carbohydrates was inadequate in approximately 85–95% of patients, while that of lipids and simple carbohydrates was inadequate in almost 50% of them. These data highlight the need to implement an effective educational program provided by certified nutritionists or dieticians, who should work in close collaboration with the hepatologist to provide a nutritional intervention tailored to the individual patient requirements.

Enhanced Recovery in Liver Transplantation: A Feasibility Study

BACKGROUND

Enhanced Recovery After Surgery (ERAS) programmes after surgery are effective in reducing length of stay, functional recovery and complication rates in liver surgery (LS) with the indirect advantage of reducing hospitalisation costs. Preoperative comorbidities, challenging surgical procedures and complex post-operative management are the points that liver transplantation (LT) shares with LS. Nevertheless, there is little evidence regarding the feasibility and safety of ERAS programmes in LT.

METHODS

We designed a pilot, small-scale, feasibility study to assess the impact on hospital stay, protocol compliance and safety of an ERAS programme tailored for LT. The ERAS arm was compared with a 1:2 match paired control arm with similar characteristics. All patients with MELD <25 were included. A dedicated LT-tailored protocol was derived from publications on ERAS liver surgery.

RESULTS

Ten patients were included in the Fast-Trans arm. It was observed a 47% reduction of the total LOS, as compared to the control arm: 9.5 (9.0-10.5) days versus 18.0 (14.3-24.3) days, respectively, p <0.001. The protocol achieved 72.9% compliance. No differences were observed in terms of post-operative complications or readmission rates after discharge between the two arms. Overall, it was observed a reduction of length of stay in ICU and surgical ward in the Fast-Trans arm compared with the control arm.

CONCLUSION

Considered the main points in common between LS and LT, this small-scale study suggests that the application of an ERAS programme tailored to the LT setting is feasible. Further testing will be appropriate to generalise these findings.

Nutrition in Alcoholic Liver Disease: An Update

Malnutrition is a change in body composition owing to disordered nutrition associated with a decrease in function and poor clinical outcomes. Malnutrition can result from overnutrition, undernutrition and inflammatory activity. Patients with alcoholic liver disease are at increased risk for malnutrition. In this article, we discuss the different methods used to assess malnutrition, prevalence of malnutrition, potential mechanisms underlying malnutrition, and its treatments in patients with alcoholic liver disease.

Impact of Prior Bariatric Surgery on Perioperative Liver Transplant Outcomes

Bariatric surgery (BS) is effective in treating morbid obesity, but the impact of prior BS on candidacy for liver transplantation (LT) is unclear. We examined 78 patients with cirrhosis with prior BS compared with a concurrent cohort of 156 patients matched by age, Model for End-Stage Liver Disease score, and underlying liver disease. We compared rates of transplant denial after evaluation, delisting on the waiting list, and survival after LT. The median time from BS to LT evaluation was 7 years. Roux-en-Y gastric bypass was the most common BS procedure performed (63% of cohort). Nonalcoholic fatty liver disease was the leading etiology for liver cirrhosis (47%). Delisting/death on the waiting list was higher among patients with BS (33.3% versus 10.1%; P = 0.002), and the transplantation rate was lower (48.9% versus 65.2%; P = 0.03). Intention-to-treat (ITT) survival from listing to 1 year after LT was lower in the BS cohort versus concurrent cohort (1-year survival, 84% versus 90%; P = 0.05). On adjusted analysis, a history of BS was associated with an increased risk of death on the waiting list (hazard ratio [HR], 5.7; 95% confidence interval [CI], 2.2-15.1), but this impact was attenuated (HR, 4.9; 95% CI, 1.8-13.4) by the presence of malnutrition. When limited to matched controls by sex, mortality attributed to BS was no longer significant for females (P = 0.37) but was significant for males (P = 0.046). Sarcopenia, as captured by skeletal muscle index, was calculated in a subset of patients (n = 49). The total skeletal surface area was lower in the BS group (127 [105-141] cm² versus 153 [131-191] cm² ; P = 0.005). Rates of sarcopenia were higher among patients delisted after listing (71.4% versus 16.7%; P = 0.04). In conclusion, a history of BS was associated with higher rates of delisting on the waiting list as well as lower survival from the time of listing on ITT analysis. Presence of malnutrition and sarcopenia among patients with BS may contribute to worse outcomes.

Optimizing the Nutritional Support of Adult Patients in the Setting of Cirrhosis

Aim: The aim of this work is to develop a pragmatic approach in the assessment and management strategies of patients with cirrhosis in order to optimize the outcomes in this patient population. Method: A systematic review of literature was conducted through 8 July 2017 on the PubMed Database looking for key terms, such as malnutrition, nutrition, assessment, treatment, and cirrhosis. Articles and studies looking at associations between nutrition and cirrhosis were reviewed. Results: An assessment of malnutrition should be conducted in two stages: the first, to identify patients at risk for malnutrition based on the severity of liver disease, and the second, to perform a complete multidisciplinary nutritional evaluation of these patients. Optimal management of malnutrition should focus on meeting recommended daily goals for caloric intake and inclusion of various nutrients in the diet. The nutritional goals should be pursued by encouraging and increasing oral intake or using other measures, such as oral supplementation, enteral nutrition, or parenteral nutrition. Conclusions: Although these strategies to improve nutritional support have been well established, current literature on the topic is limited in scope. Further research should be implemented to test if this enhanced approach is effective.