1
|
Jin W, Jiang S, Chen A, Chen Y. Effect of Preoperative Malnutrition Based on Albumin and BMI on Hepatocellular Carcinoma Surgery and Prediction of Risk Factors of Complications. J Gastrointest Cancer 2024; 55:511-518. [PMID: 38165605 DOI: 10.1007/s12029-023-01008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 01/04/2024]
Abstract
BACKGROUND To investigate the correlation between preoperative malnutrition and perioperative variables in patients with hepatocellular carcinoma (HCC) and to analyze the risk factors of complications after HCC resection. METHODS All patients who underwent hepatectomy because of HCC in the First Affiliated Hospital of Chongqing Medical University from June 1, 2018, to December 1, 2021, were analyzed retrospectively. Preoperative malnutrition was defined as body mass index (BMI) < 18.5 kg/m2 or serum albumin level < 3.5 g/dL within 30 days before operation. RESULTS A total of 415 patients with HCC hepatectomy were included, and 75 (18.1%) were classified as malnutrition group. In the malnutrition group, blood loss (662.1 ± 748.1 VS 404.6 ± 681.9, P = 0.002), transfusion rate (36.0% VS 13.5%, P < 0.001), postoperative hospital stays (13.3 ± 9.6 VS 10.1 ± 4.2, P < 0.001), 30-day postoperative mortality (4.0 VS 0.6%, P = 0.043), complications rate (68% VS 34.8%, P < 0.001), and severe complication rate (17.3% VS 2.4%, P < 0.001) were significantly higher than those in the well-nourished group. Multivariate analysis showed that age (HR 1.037, 95% CI 1.015-1.059, P = 0.001), preoperative malnutrition (HR 2.933, 95% CI 1.515-5.679, P = 0.001), simultaneous cholecystectomy (HR 2.004, 95% CI 1.168-3.440, P = 0.012), cirrhosis (HR 4.997, 95% CI 2.864-8.718, P < 0.001), and transfusion (HR 5.166, 95% CI 2.272-11.748, P < 0.001) were independent risk factors for postoperative complications. In addition, preoperative malnutrition (HR 8.209, 95% CI 2.711-24.864, P < 0.001) and operation time (HR 1.088, 95% CI 1.003-1.103, P = 0.004) were independent risk factors for severe complications. CONCLUSION Preoperative malnutrition can adversely affect the outcome of HCC resection. For patients with advanced age, cirrhosis, and malnutrition, preoperative planning is very important, and we should be more careful during the operation to avoid transfusion caused by bleeding and not to carry out preventive cholecystectomy, which are helpful to reduce the occurrence of postoperative complications.
Collapse
Affiliation(s)
- Weiqiang Jin
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Shiming Jiang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Anke Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Yong Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
| |
Collapse
|
2
|
Chapman B, Wong D, Sinclair M, Hey P, Terbah R, Gow P, Majumdar A, Testro A. Reversing malnutrition and low muscle strength with targeted enteral feeding in patients awaiting liver transplant: A randomized controlled trial. Hepatology 2024:01515467-990000000-00794. [PMID: 38456800 DOI: 10.1097/hep.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/23/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND AIMS Most patients with decompensated cirrhosis fail to meet their nutrition targets. The impact of nasogastric feeding (NGF) on malnutrition in cirrhosis remains unknown. This study aims to assess the impact of pretransplant NGF on pre-liver transplant and post-liver transplant outcomes. APPROACH AND RESULTS This single-center, prospective randomized controlled trial of 55 patients with severe malnutrition and low handgrip strength (HGS) compared a standard high-energy high-protein diet to diet plus supplemental nocturnal NGF while awaiting transplant. The primary outcome was a change in HGS. The median age was 58.5 years (IQR: 51.1-64), median MELD was 24 (20-28.5), and 32 (58%) patients were male. The median duration of NGF was 63.0 days (34.5-127), following which time the median between-group difference in HGS was 3.6 kg (95% CI: 1.7-5.2, p <0.001), an increase of 20% from baseline. Mid-upper-arm circumference, triceps skinfold, and immune function all increased significantly with NGF. Muscle and nutritional parameters continued to improve with increasing duration of feeding. NGF significantly increased daily energy intake between groups by 1285 kcal (95% CI: 860-1677) and protein intake by 51 g (95% CI: 32-71) (both p <0.001). All NGF patients met >100% of their measured nutritional requirements. Posttransplant clinical outcomes were similar between groups. CONCLUSIONS Targeted enteral feeding before liver transplant improves HGS, anthropometry, and immune function in severely malnourished patients with cirrhosis. These findings provide a strong rationale for early consideration of NGF to reverse malnutrition and improve muscle strength. Appropriately powered studies should explore whether NGF can also impact clinically relevant outcomes including pretransplant and posttransplant mortality.
Collapse
Affiliation(s)
- Brooke Chapman
- Department of Nutrition and Dietetics, Austin Health, Heidelberg, Victoria, Australia
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Darren Wong
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Penelope Hey
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Ryma Terbah
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Avik Majumdar
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Adam Testro
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
3
|
Terbah R, Testro A, Gow P, Majumdar A, Sinclair M. Portal Hypertension in Malnutrition and Sarcopenia in Decompensated Cirrhosis-Pathogenesis, Implications and Therapeutic Opportunities. Nutrients 2023; 16:35. [PMID: 38201864 PMCID: PMC10780673 DOI: 10.3390/nu16010035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
Malnutrition and sarcopenia are highly prevalent in patients with decompensated cirrhosis and are associated with poorer clinical outcomes. Their pathophysiology is complex and multifactorial, with protein-calorie malnutrition, systemic inflammation, reduced glycogen stores and hormonal imbalances all well reported. The direct contribution of portal hypertension to these driving factors is however not widely documented in the literature. This review details the specific mechanisms by which portal hypertension directly contributes to the development of malnutrition and sarcopenia in cirrhosis. We summarise the existing literature describing treatment strategies that specifically aim to reduce portal pressures and their impact on nutritional and muscle outcomes, which is particularly relevant to those with end-stage disease awaiting liver transplantation.
Collapse
Affiliation(s)
- Ryma Terbah
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Adam Testro
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Avik Majumdar
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; (R.T.); (A.T.); (P.G.); (A.M.)
- Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia
| |
Collapse
|
4
|
Chapman B, Wong D, Whitcher B, Sinclair M, Gow P, Majumdar A, Testro A. Redefining Nutritional Requirements in End-Stage Liver Disease: Towards a Personalized Approach. Nutrients 2023; 15:4770. [PMID: 38004164 PMCID: PMC10675823 DOI: 10.3390/nu15224770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Malnutrition is ubiquitous in cirrhotic patients presenting for liver transplant (LT). Providing an appropriate energy prescription is fundamental to effective nutrition therapy. We aimed to compare measured energy expenditure (mEE) with predicted energy expenditure (pEE) in patients awaiting LT and determine clinical factors associated with mEE. In this prospective observational study, energy expenditure was measured by indirect calorimetry in 110 adult patients referred for LT and predicted by commonly utilized equations (Harris-Benedict, Schofield, and EASL guidelines). Nutritional status, anthropometry, muscle function, biochemical and clinical data were also collected. The median model for end-stage liver disease (MELD) was 19 (IQR 13, 25), and the majority were Child-Pugh B (51%) or C (37%). Malnutrition was evident in 85%. Median mEE by calorimetry was 1756 (1531, 2104) kcal/d and significantly higher than pEE as per Harris-Benedict 1480 (1322, 1722) kcal/d and Schofield 1474 (1349, 1723) kcal/d (both p < 0.001), but lower than EASL guidelines (35 kcal/kg) when an activity factor was applied to mEE; 2283 (1990, 2735) kcal/d versus 2590 (2178, 3010) kcal/d (p < 0.001). Hypermetabolism (mEE:pEE > 1.2) was evident in 48% of the cohort. Multivariate analysis found MELD, Child-Pugh class, diuretic use, and severe malnutrition to be independent predictors of hypermetabolism. A new liver-specific predictive model has been developed, showing superior agreement with mEE than common predictive equations. In conclusion, there is a poor correlation between mEE and pEE in patients awaiting LTs, and hypermetabolism is common. Relying on historical predictive equations in this patient population may result in significant under or over-feeding. A tailored energy prescription based on indirect calorimetry or a liver-specific predictive model is recommended for LT candidates.
Collapse
Affiliation(s)
- Brooke Chapman
- Department of Nutrition and Dietetics, Austin Health, Heidelberg, VIC 3084, Australia
- Liver Transplant Unit, Austin Health, Heidelberg, VIC 3084, Australia; (D.W.); (B.W.); (M.S.); (P.G.); (A.M.); (A.T.)
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Darren Wong
- Liver Transplant Unit, Austin Health, Heidelberg, VIC 3084, Australia; (D.W.); (B.W.); (M.S.); (P.G.); (A.M.); (A.T.)
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Bethany Whitcher
- Liver Transplant Unit, Austin Health, Heidelberg, VIC 3084, Australia; (D.W.); (B.W.); (M.S.); (P.G.); (A.M.); (A.T.)
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, Heidelberg, VIC 3084, Australia; (D.W.); (B.W.); (M.S.); (P.G.); (A.M.); (A.T.)
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Health, Heidelberg, VIC 3084, Australia; (D.W.); (B.W.); (M.S.); (P.G.); (A.M.); (A.T.)
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Avik Majumdar
- Liver Transplant Unit, Austin Health, Heidelberg, VIC 3084, Australia; (D.W.); (B.W.); (M.S.); (P.G.); (A.M.); (A.T.)
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Adam Testro
- Liver Transplant Unit, Austin Health, Heidelberg, VIC 3084, Australia; (D.W.); (B.W.); (M.S.); (P.G.); (A.M.); (A.T.)
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia
| |
Collapse
|
5
|
Mizerska A, Durlik M, Kędzierska-Kapuza K. Nutritional Risk of Candidates for Simultaneous Pancreatic-Kidney Transplantation-A Narrative Review. Nutrients 2023; 15:4179. [PMID: 37836461 PMCID: PMC10574362 DOI: 10.3390/nu15194179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/14/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION Not much is known about the significance of nutritional status and support in transplant surgery, least of all in simultaneous pancreatic and kidney transplantation. Malnutrition in the context of simultaneous pancreatic-kidney transplantation seems to be complex and a still poorly investigated problem. Since SPKTX is highly qualified and also has a small volume procedure, it is difficult to obtain data from large cohorts of patients. The aim of this article is to gather existing evidence and information about the subject, as well as to elicit some questions and goals for the future. METHODS We searched through the Pub-Med database using the keywords "pancreas and kidney transplantation" combined with "nutritional risk", "nutritional status", "malnutrition", "nutritional intervention", and "frailty", finding a total of 4103 matching results. We then narrowed it down to articles written in English with the full text available. We also researched through the references of articles most accurately matching our researched terms. RESULTS There are numerous tools that have been investigated for the screening of malnutrition, such as the NRI index, PNI index, NLR, SGA scale, and NRS-2002 scale, each of which proved to be of some use in predicting patient outcomes in different surgical settings. Since all of them differed in components and assessed parameters and, in the absence of more sensitive or infallible indicators, the most reasonable approach seems to evaluate them jointly. CONCLUSION It is important to underline the necessity of nutritional screening and the subsequent introduction of adequate therapy while awaiting transplantation in an attempt to improve results. Considering the complexity of surgical procedures and the severity of underlying diseases with their intense metabolic components, the patient's nutritional status seems to significantly influence results. Consequently, nutritional risk assessments should be a part of the routine care of patients qualified for transplantation.
Collapse
Affiliation(s)
- Agnieszka Mizerska
- Department of Gastroenterological Surgery and Transplantology, National Medical Institute of the Ministry of Interior Affairs and Administration, Wołoska St. 137, 02-507 Warsaw, Poland;
| | - Marek Durlik
- Department of Gastroenterological Surgery and Transplantology, National Medical Institute of the Ministry of Interior Affairs and Administration, Wołoska St. 137, 02-507 Warsaw, Poland;
| | - Karolina Kędzierska-Kapuza
- Department of Gastroenterological Surgery and Transplantology, Centre of Postgraduate Medical Education, Marymoncka St. 99/103, 01-813 Warsaw, Poland
| |
Collapse
|
6
|
Limon-Miro AT, Jackson CD, Eslamparast T, Yamanaka-Okumura H, Plank LD, Henry CJ, Madden AM, Ferreira LG, Kalaitzakis E, Prieto de Frías C, Knudsen AW, Gramlich L, Raman M, Alberda C, Belland D, Den Heyer V, Tandon P, Morgan MY. Predicted estimates of resting energy expenditure have limited clinical utility in patients with cirrhosis. J Hepatol 2022; 77:98-107. [PMID: 35090958 DOI: 10.1016/j.jhep.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Malnutrition is associated with adverse clinical outcomes in patients with cirrhosis. Accurate assessment of energy requirements is needed to optimize dietary intake. Resting energy expenditure (REE), the major component of total energy expenditure, can be measured using indirect calorimetry (mREE) or estimated using prediction equations (pREE). This study assessed the usefulness of predicted estimates of REE in this patient population. METHODS Individual mREE data were available for 900 patients with cirrhosis (mean [±1 SD] age 55.7±11.6 years-old; 70% men; 52% south-east Asian) and 282 healthy controls (mean age 36.0±12.8 years-old; 52% men; 18% south-east Asian). Metabolic status was classified using thresholds based on the mean ± 1 SD of the mREE in the healthy controls. Comparisons were made between mREE and pREE estimates obtained using the Harris-Benedict, Mifflin, Schofield and Henry equations. Stepwise regression was used to build 3 new prediction models which included sex, ethnicity, body composition measures, and model for end-stage liver disease scores. RESULTS The mean mREE was significantly higher in patients than controls when referenced to dry body weight (22.4±3.8 cf. 20.8±2.6 kcal/kg/24 hr; p <0.001); there were no significant sex differences. The mean mREE was significantly higher in Caucasian than Asian patients (23.1±4.4 cf. 21.7±2.9 kcal/kg/24 hr; p <0.001). Overall, 37.1% of Caucasian and 25.3% of Asian patients were classified as hypermetabolic. The differences between mREE and pREE were both statistically and clinically relevant; in the total patient population, pREE estimates ranged from 501 kcal/24 hr less to 548 kcal/24 hr more than the mREE. Newly derived prediction equations provided better estimates of mREE but still had limited clinical utility. CONCLUSIONS Prediction equations do not provide useful estimates of REE in patients with cirrhosis. REE should be directly measured. LAY SUMMARY People with cirrhosis are often malnourished and this has a detrimental effect on outcome. Provision of an adequate diet is very important and is best achieved by measuring daily energy requirements and adjusting dietary intake accordingly. Prediction equations, which use information on age, sex, weight, and height can be used to estimate energy requirements; however, the results they provide are not accurate enough for clinical use, particularly as they vary according to sex and ethnicity.
Collapse
Affiliation(s)
| | - Clive Douglas Jackson
- Department of Clinical Neurophysiology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | | | - Hisami Yamanaka-Okumura
- Department of Clinical Nutrition and Food Management, Institute of Biomedical Sciences, Tokushima University Graduate School, Kuramoto-cho, Tokushima, Japan
| | | | | | - Angela Mary Madden
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Livia Garcia Ferreira
- Graduate Program in Nutrition and Health, Department of Nutrition, Universidade Federal de Lavras, Brazil
| | - Evangelos Kalaitzakis
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital Herlev, Denmark; Department of Gastroenterology, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | | | - Anne Wilkens Knudsen
- Gastrounit, Medical Division, Copenhagen University Hospital - Hvidovre, Denmark
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Maitreyi Raman
- Department of Medicine, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Alberda
- Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada
| | - Dawn Belland
- University of Alberta Hospital, Alberta Health Services Nutrition Services, Edmonton, Canada
| | - Vanessa Den Heyer
- University of Alberta Hospital, Alberta Health Services Nutrition Services, Edmonton, Canada
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, Canada.
| | - Marsha Yvonne Morgan
- UCL Institute for Liver & Digestive Health, Division of Medicine, Royal Free Campus, University College London, UK.
| |
Collapse
|
7
|
Marderfeld L, Waisbourd-Zinman O, Biran N, Rozenfeld Bar-Lev M, Silbermintz A, Poraz I, Reznik D, Jack Y, Mozer Glassberg Y, Shamir R. Body composition correlates with laboratory parameters and disease severity in infants with biliary atresia. Pediatr Transplant 2022; 26:e14208. [PMID: 34927330 DOI: 10.1111/petr.14208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/13/2021] [Accepted: 11/26/2021] [Indexed: 11/27/2022]
Abstract
AIM Infants with biliary atresia (BA) generally have chronic malnutrition. However, the best anthropometric measure to assess malnutrition and its correlation with disease severity is unknown. We aimed to assess correlations of various anthropometric measurements, including air displacement plethysmography (ADP), with laboratory parameters and with the pediatric end-stage liver disease (PELD) score in infants with BA. METHODS Infants with BA were followed at a pediatric liver transplantation center during 2014-2018. Follow-up comprised laboratory tests and nutritional assessment by a dietitian including dietary intake, weight, height, mid-upper arm circumference (MUAC), and skin-fold thickness. Fat-free mass (FFM) and fat mass (FM) were measured by ADP. RESULTS Forty-three nutritional evaluations were performed in 28 infants with BA (13 boys, 44.4%). The median age was 20.7 weeks (IQR: 13-25.9). Based on the various anthropometry modalities, infants with BA were found to be malnourished on most of the visits; 63% had a MUAC-Z score lower than -2 standard deviations. High serum bilirubin level predicted lower weight for age, length for age, and MUAC-Z. Lower MUAC-Z was associated with a higher PELD score. Neither FM mass nor FFM correlated with PELD or with serum bilirubin level. However, FM correlated with skin-fold thickness-Z and was low in most patients. CONCLUSIONS The majority of BA infants suffer from malnutrition as assessed by most anthropometrics modalities; low MUAC correlated best with disease severity and serum bilirubin level. Further studies are warranted to determine the contribution of FM measurement by ADP to the anthropometric assessment of infants with BA.
Collapse
Affiliation(s)
- Luba Marderfeld
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Nutrition and Dietetics Department, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Orith Waisbourd-Zinman
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Neta Biran
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Nutrition and Dietetics Department, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Michal Rozenfeld Bar-Lev
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Ari Silbermintz
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Irit Poraz
- Nutrition and Dietetics Department, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,National Management Office, Clalit Health Services Tel Aviv, Tel Aviv, Israel
| | - Dana Reznik
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Nutrition and Dietetics Department, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Yifat Jack
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Nutrition and Dietetics Department, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Yael Mozer Glassberg
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,National Management Office, Clalit Health Services Tel Aviv, Tel Aviv, Israel
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,National Management Office, Clalit Health Services Tel Aviv, Tel Aviv, Israel
| |
Collapse
|
8
|
Lee DU, Fan GH, Hastie DJ, Addonizio EA, Prakasam VN, Ahern RR, Seog KJ, Karagozian R. The Impact of Malnutrition on the Hospital and Infectious Outcomes of Patients Admitted With Alcoholic Hepatitis: 2011 to 2017 Analysis of US Hospitals. J Clin Gastroenterol 2022; 56:349-359. [PMID: 33769393 DOI: 10.1097/mcg.0000000000001528] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/06/2021] [Indexed: 01/13/2023]
Abstract
GOALS We specifically evaluate the effect of malnutrition on the infection risks of patients admitted with alcoholic hepatitis using a national registry of hospitalized patients in the United States. BACKGROUND Malnutrition is a common manifestation of alcoholic hepatitis that affects patient outcomes. STUDY 2011 to 2017 National Inpatient Sample was used to isolated patients with alcoholic hepatitis, stratified using malnutrition (protein-calorie malnutrition, sarcopenia, and weight loss/cachexia) and matched using age, gender, and race with 1:1 nearest neighbor matching method. Endpoints included mortality and infectious endpoints. RESULTS After matching, there were 10,520 with malnutrition and 10,520 malnutrition-absent controls. Mortality was higher in the malnutrition cohort [5.02 vs. 2.29%, P<0.001, odds ratio (OR): 2.25, 95% confidence interval (CI): 1.93-2.63], as were sepsis (14.2 vs. 5.46, P<0.001, OR: 2.87, 95% CI: 2.60-3.18), pneumonia (10.9 vs. 4.63%, P<0.001, OR: 2.51, 95% CI: 2.25-2.81), urinary tract infection (14.8 vs. 9.01%, P<0.001, OR: 1.76, 95% CI: 1.61-1.91), cellulitis (3.17 vs. 2.18%, P<0.001, OR: 1.47, 95% CI: 1.24-1.74), cholangitis (0.52 vs. 0.20%, P<0.001, OR: 2.63, 95% CI: 1.59-4.35), and Clostridium difficile infection (1.67 vs. 0.91%, P<0.001, OR: 1.85, 95% CI: 1.44-2.37). In multivariate models, malnutrition was associated with mortality [P<0.001, adjusted odds ratio (aOR): 1.61, 95% CI: 1.37-1.90] and infectious endpoints: sepsis (P<0.001, aOR: 2.42, 95% CI: 2.18-2.69), pneumonia (P<0.001, aOR: 2.19, 95% CI: 1.96-2.46), urinary tract infection (P<0.001, aOR: 1.68, 95% CI: 1.53-1.84), cellulitis (P<0.001, aOR: 1.46, 95% CI: 1.22-1.74), cholangitis (P=0.002, aOR: 2.27, 95% CI: 1.36-3.80), and C. difficile infection (P<0.001, aOR: 1.89, 95% CI: 1.46-2.44). CONCLUSION This study shows the presence of malnutrition is an independent risk factor of mortality and local/systemic infections in patients admitted with alcoholic hepatitis.
Collapse
Affiliation(s)
- David U Lee
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Washington Street, Boston, MA
| | | | | | | | | | | | | | | |
Collapse
|
9
|
Malnutrition and low muscle strength are independent predictors of clinical outcomes and healthcare costs after liver transplant. Clin Nutr ESPEN 2022; 48:210-219. [DOI: 10.1016/j.clnesp.2022.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/14/2022] [Indexed: 11/21/2022]
|
10
|
Grover I, Singh N, Gunjan D, Pandey RM, Chandra Sati H, Saraya A. Comparison of Anthropometry, Bioelectrical Impedance, and Dual-energy X-ray Absorptiometry for Body Composition in Cirrhosis. J Clin Exp Hepatol 2022; 12:467-474. [PMID: 35535105 PMCID: PMC9077186 DOI: 10.1016/j.jceh.2021.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/29/2021] [Indexed: 12/12/2022] Open
Abstract
Background & aims This study was planned to evaluate triceps skinfold thickness (TSFT), mid-arm muscle circumference (MAMC) and bioelectrical impedance analysis (BIA) for assessing body composition using dual-energy X-ray absorptiometry (DEXA) (reference) and to predict fat mass (FM) and fat-free mass (FFM) in patients with cirrhosis. Methods FM and FFM were assessed by using DEXA and BIA. Skin-fold calliper was used for measuring TSFT, and MAMC was calculated. Bland-Altman plot was used to determine agreement and linear regression analysis for obtaining equations to predict FM and FFM. Results Patients with cirrhosis (n = 302, 241 male, age 43.7 ± 12.0 years) were included. Bland-Altman plot showed very good agreement between BIA and DEXA for the estimation of FM and FFM. Majority of patients were within the limit of agreement: FM (98%) and FFM (96.4%). BIA shows a positive correlation with DEXA:FM (r = 0.73, P ≤ 0.001) and FFM (r = 0.86, P ≤ 0.001). DEXA (FM and FFM) shows a positive correlation with TSFT (r = 0.69, P ≤ 0.01) and MAMC (r = 0.61, P ≤ 0.01). The mean difference between the observed and predicted value of FM and FFM by BIA in the developmental set was 0.01 and 0.05, respectively; whereas in the validation set, it was -0.13 and 0.86, respectively. The mean difference between the observed and predicted value of TSFT and MAMC in the developmental set was 0.43 and 0.07; whereas, in the validation set, it was 0.16 and 0.48, respectively. Conclusion Anthropometry (TSFT and MAMC) and BIA are simple and easy to use and can be a substitute of DEXA for FM and FFM assessment in routine clinical settings in patients with cirrhosis.
Collapse
Key Words
- ALP, alkaline phosphatise
- ALT, alanine aminotransferase
- ANA, anti-nuclear antibody
- ASMA, anti-smooth muscle antibody
- AST, aspartate aminotransferase
- BIA, bioelectrical impedance analysis
- BMC, bone mineral content
- BMI, body mass index
- CTP, Child–Turcotte–Pugh score
- DEXA, dual-energy X-ray absorptiometry
- FFM, fat-free mass
- FM, fat mass
- HBsAg, hepatitis B surface antigen
- MAMC, mid-arm muscle circumference
- TSFT, triceps skinfold thickness
- anthropometric measurements
- anti-HCV, anti-hepatitis C virus
- anti-LKM1, anti-liver kidney microsomal antibody type 1
- bioelectrical impedance analysis
- cirrhosis
- dual-energy X-ray absorptiometry
- nutritional assessment
Collapse
Affiliation(s)
- Indu Grover
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, N. Delhi, India
| | - Namrata Singh
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, N. Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, N. Delhi, India
| | - Ravindra M. Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, N. Delhi, India
| | - Hem Chandra Sati
- Department of Biostatistics, All India Institute of Medical Sciences, N. Delhi, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, N. Delhi, India,Address for correspondence: Anoop Saraya, Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, N. Delhi, India.
| |
Collapse
|
11
|
Sciarrone SS, Zanetto A, Russo FP, Germani G, Gambato M, Battistella S, Pellone M, Shalaby S, Burra P, Senzolo M. Malnourished cirrhotic patient: what should we do? Minerva Gastroenterol (Torino) 2021; 67:11-22. [PMID: 33784807 DOI: 10.23736/s2724-5985.20.02776-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Malnutrition and sarcopenia have a high prevalence in cirrhotic patients. Frailty generally overlaps with malnutrition and sarcopenia in cirrhosis, leading to increased morbidity and mortality. Rapid nutritional screening assessment should be performed in all patients with cirrhosis, and more specific tests for sarcopenia should be performed in those at high risk. The pathogenesis of malnutrition in cirrhosis is complex and multifactorial and it is not just due to reduction in protein and calorie intake. Nutritional management in malnourished patients with cirrhosis should be undertaken by a multidisciplinary team to achieve adequate protein/calorie intake. While the role of branched-chained amino acids remains somewhat contentious in achieving a global benefit of decreasing mortality- and liver-related events, these latter and vitamin supplements, are recommended for those with advanced liver disease. Novel strategies to reverse sarcopenia such as hormone supplementation, long-term ammonia-lowering agents and myostatin antagonists, are currently under investigation. Malnutrition, sarcopenia and frailty are unique, inter-related and multidimensional problems in cirrhosis which require special attention, prompt assessment and appropriate management as they significantly impact morbidity and mortality.
Collapse
Affiliation(s)
- Salvatore S Sciarrone
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Alberto Zanetto
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Francesco P Russo
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Giacomo Germani
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Martina Gambato
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Sara Battistella
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Monica Pellone
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Sarah Shalaby
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Patrizia Burra
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Marco Senzolo
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy -
| |
Collapse
|
12
|
Chan KS, Chia CLK, Ng FKL, Seow WHJ, Leong DY, Shelat VG. Impaired Handgrip Strength Does Not Predict Postoperative Morbidity in Major Hepatobiliary Surgery. J Surg Res 2020; 256:549-556. [PMID: 32799004 DOI: 10.1016/j.jss.2020.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 06/18/2020] [Accepted: 07/11/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Assessment of preoperative handgrip strength (HGS) is an objective and inexpensive bedside tool, which has been investigated to predict morbidity risk in elective surgery. However, its use is not validated in patients undergoing major elective hepatobiliary surgery (MEHS). The aim of this study is to investigate the use of HGS to predict morbidity in patients undergoing MEHS. METHODS This is a single-center prospective study involving 81 patients who underwent MEHS over 21 mo from July 2014 to March 2016. MEHS was defined as any hepatobiliary surgery expected to last more than 2 h and/or with an anticipated blood loss of ≥500 mL. HGS was assessed in both dominant and nondominant hands with standardization and subsequently recorded and expressed as a percentage of a general, age- and gender-matched normative values. RESULTS The mean age was 65.2 ± 9.5 y with male predominance (n = 52, 64.2%). Approximately, half of the patients underwent liver resection (n = 43, 53.1%). There was no difference in the incidence of Clavien-Dindo ≥ grade IIIA in both dominant HGS (impaired HGS 8/33 [24.2%], normal HGS 6/48 [12.5%]; P = 0.170) and nondominant HGS (impaired HGS 8/33 [21.1%], normal HGS 6/43 [14%]; P = 0.399). Dominant and nondominant HGS showed poor discriminatory ability in the prediction of Clavien-Dindo ≥ grade IIIA complications (dominant HGS area under the curve [AUC] = 0.572; nondominant HGS AUC 0.545). However, the use of dominant HGS showed moderate discriminatory ability to predict the length of hospital stay ≥21 d (AUC = 0.759). CONCLUSIONS The use of HGS may not predict Clavien-Dindo ≥ grade IIIA complications, but predicts a prolonged length of hospital stay ≥21 d.
Collapse
Affiliation(s)
- Kai Siang Chan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | - Felicia Kai Lin Ng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore.
| |
Collapse
|
13
|
Chapman B, Sinclair M, Gow PJ, Testro AG. Malnutrition in cirrhosis: More food for thought. World J Hepatol 2020; 12:883-896. [PMID: 33312416 PMCID: PMC7701970 DOI: 10.4254/wjh.v12.i11.883] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/08/2020] [Accepted: 10/20/2020] [Indexed: 02/06/2023] Open
Abstract
Malnutrition is highly prevalent in liver cirrhosis and its presence carries important prognostic implications. The clinical conditions and pathophysiological mechanisms that cause malnutrition in cirrhosis are multiple and interrelated. Anorexia and liver decompensation symptoms lead to poor dietary intake; metabolic changes characterised by elevated energy expenditure, reduced glycogen storage, an accelerated starvation response and protein catabolism result in muscle and fat wasting; and, malabsorption renders the cirrhotic patient unable to fully absorb or utilise food that has been consumed. Malnutrition is therefore a considerable challenge to manage effectively, particularly as liver disease progresses. A high energy, high protein diet is recognised as standard of care, yet patients struggle to follow this recommendation and there is limited evidence to guide malnutrition interventions in cirrhosis and liver transplantation. In this review, we seek to detail the factors which contribute to poor nutritional status in liver disease, and highlight complexities far greater than "poor appetite" or "reduced oral intake" leading to malnutrition. We also discuss management strategies to optimise nutritional status in this patient group, which target the inter-related mechanisms unique to advanced liver disease. Finally, future research requirements are suggested, to develop effective treatments for one of the most common and debilitating complications afflicting cirrhotic patients.
Collapse
Affiliation(s)
- Brooke Chapman
- Nutrition and Dietetics Department, Austin Health, Heidelberg 3084, Australia.
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
| | - Paul J Gow
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
| | - Adam G Testro
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
| |
Collapse
|
14
|
Lobo DN, Gianotti L, Adiamah A, Barazzoni R, Deutz NEP, Dhatariya K, Greenhaff PL, Hiesmayr M, Hjort Jakobsen D, Klek S, Krznaric Z, Ljungqvist O, McMillan DC, Rollins KE, Panisic Sekeljic M, Skipworth RJE, Stanga Z, Stockley A, Stockley R, Weimann A. Perioperative nutrition: Recommendations from the ESPEN expert group. Clin Nutr 2020; 39:3211-3227. [PMID: 32362485 DOI: 10.1016/j.clnu.2020.03.038] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14-15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients. METHODS This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art. RESULTS Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer. CONCLUSIONS Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient.
Collapse
Affiliation(s)
- Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK.
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca, Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Alfred Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Rocco Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Nicolaas E P Deutz
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, College Station, TX, 77843-4253, USA
| | - Ketan Dhatariya
- Department of Diabetes, Endocrinology and General Medicine, Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust and University of East Anglia, Colney Lane, Norwich, NR4 7UY, UK
| | - Paul L Greenhaff
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Michael Hiesmayr
- Division of Cardio-Thoracic-Vascular Surgical Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Stanislaw Klek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - Zeljko Krznaric
- University Hospital Centre Zagreb and Zagreb School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Donald C McMillan
- Academic Unit of Surgery, School of Medicine, University of Glasgow, Royal Infirmary, Glasgow, UK
| | - Katie E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Marina Panisic Sekeljic
- Military Medical Academy, Clinic for General Surgery, Department for Perioperative Nutrition, Crnostravska Street 17, Belgrade, Serbia
| | - Richard J E Skipworth
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Zeno Stanga
- Division of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Audrey Stockley
- Patient Public Involvement Group, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Ralph Stockley
- Patient Public Involvement Group, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Arved Weimann
- Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg gGmbH, Delitzscher Straße 141, 04129, Leipzig, Germany
| |
Collapse
|
15
|
Lee B, Han HS, Yoon YS, Cho JY, Lee JS. Impact of preoperative malnutrition, based on albumin level and body mass index, on operative outcomes in patients with pancreatic head cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:1069-1075. [PMID: 33128839 DOI: 10.1002/jhbp.858] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/20/2020] [Accepted: 10/14/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND To investigate whether preoperative malnutrition in patients who underwent curative pancreaticoduodenectomy (PD) in pancreatic head cancer correlated with short-term outcomes. METHODS This study was a retrospective review of medical records from January 2004 to December 2018. Preoperative malnutrition was defined as body mass index (BMI) <18.5 kg/m2 , or hypoalbuminemia with serum albumin level < 3.5 g/dL within 30 days before surgery. RESULTS Of the 289 eligible patients, 60 patients (20.7%) were classified as the malnutrition group. The estimated blood loss (EBL, mL) (964.1 ± 879.7 vs 597.7 ± 501.7, P = .044) and transfusion rate (51.7% vs 18.8%, P < .001) was significantly higher in the malnutrition group than no-malnutrition group. The hospital stay (days) (20.5 ± 12.2 vs 18.1 ± 13.6, P = .05) was significantly longer in the malnutrition group. The open conversion rate (45.4% vs 6.67%, P < .001) and major complication rate (36.7% vs 21.8%, P = .032) was significantly higher in the malnutrition group. In multivariate analysis, preoperative malnutrition was found to be the predictor of postoperative complication (HR 1.971 95% confidence interval 1.071-3.624, P = .029). CONCLUSION Preoperative malnutrition in patients who underwent curative PD for pancreatic head cancer is associated with adverse short-term outcomes.
Collapse
Affiliation(s)
- Boram Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea.,Seoul National University College of Medicine, Seoul, Korea
| | - Ho-Seong Han
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea.,Seoul National University College of Medicine, Seoul, Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea.,Seoul National University College of Medicine, Seoul, Korea
| | - Jai Young Cho
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea.,Seoul National University College of Medicine, Seoul, Korea
| | - Jun Suh Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea.,Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
16
|
Crisan D, Procopet B, Epure A, Stefanescu H, Suciu A, Fodor A, Mois E, Craciun R, Crisan N. Malnutrition and non-compliance to nutritional recommendations in patients with cirrhosis are associated with a lower survival. World J Hepatol 2020; 12:829-840. [PMID: 33200020 PMCID: PMC7643216 DOI: 10.4254/wjh.v12.i10.829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/06/2020] [Accepted: 09/04/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Malnutrition is frequently encountered in patients with cirrhosis and appears to significantly impact their prognosis. While evaluating the burden of malnutrition in cirrhosis is gathering momentum, as suggested by multiple recently published reports, there is still a persistent scarcity of solid data in the field, especially with regards to the role of nutritional interventions.
AIM To assess the prevalence of malnutrition in patients with advanced cirrhosis and to evaluate its impact on survival.
METHODS One hundred and one consecutive patients with advanced cirrhosis were screened for malnutrition using the Subjective Global Assessment (SGA) criteria and the mid-arm circumference (MAC). Malnutrition was defined as SGA class B and C and MAC < 10th percentile. All patients were interviewed regarding their food intake using an adapted questionnaire. Subsequently, total energy intake was calculated and further subdivided in main nutrients. The data were then compared to the available recommendations at the time of analysis to assess adherence.
RESULTS 54/79 patients (68.4%) in the decompensated group had malnutrition, while only 3/22 patients (13.6%) were malnourished in the compensated group. After a median follow-up time of 27 mo (0-53), the overall mortality was 70%. Survival was significantly lower among patients with malnutrition. The mortality rates were 50% 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, the factors independently associated with mortality were age, creatinine level and adherence to the protein intake recommendations. The mortality was lower in patients with the appropriate protein intake: 8% at 1 year and 28% at 2 years in the adherent group, compared to 47% at 1 year and 56% at 2 years in the non-adherent group.
CONCLUSION The prevalence of malnutrition is high among patients with advanced cirrhosis and might be related in part to a low adherence to nutritional recommendations, especially with regards to protein intake.
Collapse
Affiliation(s)
- Dana Crisan
- Internal Medicine Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca 400126, Romania
| | - Bogdan Procopet
- 3rd Medical Clinic, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca 400126, Romania
- Hepatology Unit, “Prof. Dr. Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Alexandra Epure
- 3rd Medical Clinic, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca 400126, Romania
| | - Horia Stefanescu
- Hepatology Unit, “Prof. Dr. Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Alina Suciu
- 3rd Medical Clinic, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca 400126, Romania
| | - Andreea Fodor
- 3rd Medical Clinic, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca 400126, 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
| | - Nicolae Crisan
- Internal Medicine Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca 400126, Romania
| |
Collapse
|
17
|
Bischoff SC, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, Plauth M. ESPEN practical guideline: Clinical nutrition in liver disease. Clin Nutr 2020; 39:3533-3562. [PMID: 33213977 DOI: 10.1016/j.clnu.2020.09.001] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Practical guideline is based on the current scientific ESPEN guideline on Clinical Nutrition in Liver Disease. METHODS It has been shortened and transformed into flow charts for easier use in clinical practice. The guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with chronic liver disease. RESULTS A total of 103 statements and recommendations are presented with short commentaries for the nutritional and metabolic management of patients with (i) acute liver failure, (ii) alcoholic steatohepatitis, (iii) non-alcoholic fatty liver disease, (iv) liver cirrhosis, and (v) liver surgery/transplantation. The disease-related recommendations are preceded by general recommendations on the diagnostics of nutritional status in liver patients and on liver complications associated with medical nutrition. CONCLUSION This practical guideline gives guidance to health care providers involved in the management of liver disease to offer optimal nutritional care.
Collapse
Affiliation(s)
- Stephan C Bischoff
- Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany.
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Lindsay D Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Tatjana Schütz
- IFB Adiposity Diseases, Leipzig University Medical Centre, Leipzig, Germany
| | - Mathias Plauth
- Department of Internal Medicine, Municipal Hospital of Dessau, Dessau, Germany
| |
Collapse
|
18
|
Ney M, Li S, Vandermeer B, Gramlich L, Ismond KP, Raman M, Tandon P. Systematic review with meta-analysis: Nutritional screening and assessment tools in cirrhosis. Liver Int 2020; 40:664-673. [PMID: 31571398 DOI: 10.1111/liv.14269] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 08/09/2019] [Accepted: 09/05/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Disease-related malnutrition is common in cirrhosis. Multiple studies have evaluated nutritional screening tools (NSTs, rapid bedside tests targeting who needs assessment) and nutritional assessment tools (NATs, used in diagnosing malnutrition) as predictors of clinical outcome in this population. We performed a systematic review and meta-analysis of this literature with the aim of summarising the varying definitions of malnutrition across studies, the available evidence for NSTs and the ability of NSTs and NATs to predict clinical outcomes in cirrhosis. METHODS The primary outcome measures were pre- and post-transplant mortality with a range of secondary outcomes. Inclusion: cirrhosis over age 16. Exclusion: >25% with hepatocellular carcinoma, primarily laboratory test-based NATs or lack of screening, assessment or outcome criteria. RESULTS Eight thousand eight hundred fifty patients were included across 47 studies. Only 3 studies assessed NSTs. Thirty-two definitions for malnutrition were utilised across studies. NATs predicted pre-transplant mortality in 69% of cases that were assessed with a risk ratio (RR) of 2.38 (95% CI 1.96-2.89). NATs were prognostic for post-transplant mortality only 28% of the times they were assessed, with a RR of 3.04 (95% CI 1.51-6.12). CONCLUSIONS The cirrhosis literature includes limited data on nutrition screening and multiple definitions for what constitutes malnutrition using NATs. Despite this discordance, it is clear that malnutrition is a valuable predictor of pre-transplant mortality almost regardless of how it is defined. We require clinical and research consensus around the definition of malnutrition and the accepted processes and cut-points for nutrition screening and assessment in cirrhosis.
Collapse
Affiliation(s)
- Michael Ney
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Suqing Li
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, AB, Canada
| | - Leah Gramlich
- Royal Alexandra Hospital, University of Alberta, Edmonton, AB, Canada
| | - Kathleen P Ismond
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Maitreyi Raman
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Puneeta Tandon
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
19
|
An Outpatient Hospital-based Exercise Training Program for Patients With Cirrhotic Liver Disease Awaiting Transplantation: A Feasibility Trial. Transplantation 2020; 104:97-103. [DOI: 10.1097/tp.0000000000002803] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
20
|
Al-Judaibi B, Alqalami I, Sey M, Qumosani K, Howes N, Sinclair L, Chandok N, Eddin AH, Hernandez-Alejandro R, Marotta P, Teriaky A. Exercise Training for Liver Transplant Candidates. Transplant Proc 2019; 51:3330-3337. [DOI: 10.1016/j.transproceed.2019.08.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 08/30/2019] [Indexed: 02/06/2023]
|
21
|
Abstract
Patients with portal hypertension will increasingly present for nontransplant surgery because of the increasing incidence of, and improving long-term survival for, chronic liver disease. Such patients have increased perioperative morbidity and mortality caused by the systemic pathophysiology of liver disease. Preoperative assessment should identify modifiable causes of liver injury and distinguish between compensated and decompensated cirrhosis. Risk stratification, which is crucial to preparing patients and their families for surgery, relies on scores such as Child-Turcotte-Pugh and Model for End-stage Liver Disease to translate disease severity into quantified outcomes predictions. Risk factors for postoperative complications should also be recognized.
Collapse
Affiliation(s)
- Melissa Wong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Transplant Center, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Ronald W Busuttil
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, The Dumont-UCLA Transplant Center, 757 Westwood Blvd, Suite 8236, Los Angeles, CA 90095, USA.
| |
Collapse
|
22
|
Abstract
Sarcopenia, frailty, and malnutrition are prevalent complications in patients with end-stage liver disease (ESLD) and are associated with increased risk of morbidity and mortality. It is valuable to measure nutritional status, sarcopenia, and frailty over time in order to create interventions tailored to individuals with ESLD. Evaluating sarcopenia and frailty in patients with ESLD is challenging. Further work is needed to perfect these assessments so that clinicians can incorporate these assessments into their decision-making and management plans for cirrhotic patients.
Collapse
Affiliation(s)
- Elizabeth S Aby
- Department of Medicine, University of California at Los Angeles, UCLA Medical Center, 757 Westwood Plaza, Suite 7501, Los Angeles, CA 90095, USA. https://twitter.com/lizabmn47
| | - Sammy Saab
- Department of Medicine, University of California at Los Angeles, UCLA Medical Center, 757 Westwood Plaza, Suite 7501, Los Angeles, CA 90095, USA; Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA.
| |
Collapse
|
23
|
Reber E, Gomes F, Vasiloglou MF, Schuetz P, Stanga Z. Nutritional Risk Screening and Assessment. J Clin Med 2019; 8:jcm8071065. [PMID: 31330781 PMCID: PMC6679209 DOI: 10.3390/jcm8071065] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/03/2019] [Accepted: 07/09/2019] [Indexed: 01/04/2023] Open
Abstract
Malnutrition is an independent risk factor that negatively influences patients’ clinical outcomes, quality of life, body function, and autonomy. Early identification of patients at risk of malnutrition or who are malnourished is crucial in order to start a timely and adequate nutritional support. Nutritional risk screening, a simple and rapid first-line tool to detect patients at risk of malnutrition, should be performed systematically in patients at hospital admission. Patients with nutritional risk should subsequently undergo a more detailed nutritional assessment to identify and quantify specific nutritional problems. Such an assessment includes subjective and objective parameters such as medical history, current and past dietary intake (including energy and protein balance), physical examination and anthropometric measurements, functional and mental assessment, quality of life, medications, and laboratory values. Nutritional care plans should be developed in a multidisciplinary approach, and implemented to maintain and improve patients’ nutritional condition. Standardized nutritional management including systematic risk screening and assessment may also contribute to reduced healthcare costs. Adequate and timely implementation of nutritional support has been linked with favorable outcomes such as a decrease in length of hospital stay, reduced mortality, and reductions in the rate of severe complications, as well as improvements in quality of life and functional status. The aim of this review article is to provide a comprehensive overview of nutritional screening and assessment methods that can contribute to an effective and well-structured nutritional management (process cascade) of hospitalized patients.
Collapse
Affiliation(s)
- Emilie Reber
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, and University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland.
| | - Filomena Gomes
- The New York Academy of Sciences, 250 Greenwich Sweet, 40th floor, New York, NY 10007, USA
| | - Maria F Vasiloglou
- Diabetes Technology Research Group, ARTORG Center for Biomedical Engineering Research, University of Bern, Murtenstrasse 50, 3008 Bern, Switzerland
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, Tellstrasse 25, 5000 Aarau, Switzerland
- Department for Clinical Research, Medical Faculty, University of Basel, 4001 Basel, Switzerland
| | - Zeno Stanga
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, and University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| |
Collapse
|
24
|
Ribeiro HS, Coury NC, de Vasconcelos Generoso S, Lima AS, Correia MITD. Energy Balance and Nutrition Status: A Prospective Assessment of Patients Undergoing Liver Transplantation. Nutr Clin Pract 2019; 35:126-132. [DOI: 10.1002/ncp.10323] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Helem Sena Ribeiro
- Surgery Post Graduation Program; Medical School; Universidade Federal de Minas Gerais; Belo Horizonte Brazil
| | - Nayhara Castro Coury
- Nutrition Department; Nursing School; Universidade Federal de Minas Gerais; Belo Horizonte Brazil
| | | | - Agnaldo Soares Lima
- Alfa Institute of Gastroenterology; Hospital of Clinics; Medical School; Universidade Federal de Minas Gerais; Belo Horizonte Brazil
| | - Maria Isabel Toulson Davisson Correia
- Surgery Post Graduation Program; Medical School; Universidade Federal de Minas Gerais; Belo Horizonte Brazil
- Alfa Institute of Gastroenterology; Hospital of Clinics; Medical School; Universidade Federal de Minas Gerais; Belo Horizonte Brazil
| |
Collapse
|
25
|
Suárez-Llanos JP, Rosat-Rodrigo A, García-Niebla J, Vallejo-Torres L, Delgado-Brito I, García-Bello MA, Pereyra-García-Castro F, Barrera-Gómez MA. Comparison of Clinical Outcomes in Surgical Patients Subjected to CIPA Nutrition Screening and Treatment versus Standard Care. Nutrients 2019; 11:E889. [PMID: 31010007 PMCID: PMC6520912 DOI: 10.3390/nu11040889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/13/2019] [Accepted: 04/17/2019] [Indexed: 12/20/2022] Open
Abstract
Malnutrition is prevalent in surgical patients and leads to comorbidities and a poorer postoperative course. There are no studies that compare the clinical outcomes of implementing a nutrition screening tool in surgical patients with standard clinical practice. An open, non-randomized, controlled study was conducted in general and digestive surgical hospitalized patients, who were either assigned to standard clinical care or to nutrition screening using the Control of Food Intake, Protein, and Anthropometry (CIPA) tool and an associated treatment protocol (n = 210 and 202, respectively). Length of stay, mortality, readmissions, in-hospital complications, transfers to critical care units, and reinterventions were evaluated. Patients in the CIPA group had a higher Charlson index on admission and underwent more oncological and hepatobiliary-pancreatic surgeries. Although not significant, a shorter mean length of stay was observed in the CIPA group (-1.48 days; p < 0.246). There were also fewer cases of exitus (seven vs. one) and fewer transfers to critical care units in this group (p = 0.068 for both). No differences were detected in other clinical variables. In conclusion, patients subjected to CIPA nutrition screening and treatment showed better clinical outcomes than those receiving usual clinical care. The results were not statistically significant, possibly due to the heterogeneity across patient groups.
Collapse
Affiliation(s)
- José Pablo Suárez-Llanos
- Endocrinology and Nutrition Department, University Hospital Nuestra Señora de Candelaria (HUNSC), 38010 Santa Cruz de Tenerife, Spain.
| | - Adriá Rosat-Rodrigo
- General and Digestive Surgery Department, HUNSC, 38010 Santa Cruz de Tenerife, Spain.
| | | | - Laura Vallejo-Torres
- Department of Quantitative Methods in Economics and Management, University of Las Palmas de Gran Canaria, 35001 Las Palmas de Gran Canaria, Spain.
- Canary Islands Foundation for Health Research (FUNCANIS), 38109 Santa Cruz de Tenerife, Spain.
- Health Services Research on Chronic Patients Network (REDISSEC), 38010 Santa Cruz de Tenerife, Spain.
| | - Irina Delgado-Brito
- Canary Islands Cancer Research Institute (FICIC), 38204 Santa Cruz de Tenerife, Spain.
| | - Miguel A García-Bello
- Department of Clinical Epidemiology and Biostatistics, HUNSC; Primary Care Management, 38010 Santa Cruz de Tenerife, Spain.
| | - Francisca Pereyra-García-Castro
- Endocrinology and Nutrition Department, University Hospital Nuestra Señora de Candelaria (HUNSC), 38010 Santa Cruz de Tenerife, Spain.
| | | |
Collapse
|
26
|
Plauth M, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, Bischoff SC. ESPEN guideline on clinical nutrition in liver disease. Clin Nutr 2019; 38:485-521. [PMID: 30712783 DOI: 10.1016/j.clnu.2018.12.022] [Citation(s) in RCA: 250] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 02/06/2023]
Abstract
This update of evidence-based guidelines (GL) aims to translate current evidence and expert opinion into recommendations for multidisciplinary teams responsible for the optimal nutritional and metabolic management of adult patients with liver disease. The GL was commissioned and financially supported by ESPEN. Members of the guideline group were selected by ESPEN. We searched for meta-analyses, systematic reviews and single clinical trials based on clinical questions according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing the SIGN method. A total of 85 recommendations were made for the nutritional and metabolic management of patients with acute liver failure, severe alcoholic steatohepatitis, non-alcoholic fatty liver disease, liver cirrhosis, liver surgery and transplantation as well as nutrition associated liver injury distinct from fatty liver disease. The recommendations are preceded by statements covering current knowledge of the underlying pathophysiology and pathobiochemistry as well as pertinent methods for the assessment of nutritional status and body composition.
Collapse
Affiliation(s)
- Mathias Plauth
- Department of Internal Medicine, Municipal Hospital of Dessau, Dessau, Germany.
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Lindsay D Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Tatjana Schütz
- IFB Adiposity Diseases, Leipzig University Medical Centre, Leipzig, Germany
| | - Stephan C Bischoff
- Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany
| |
Collapse
|
27
|
EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol 2019; 70:172-193. [PMID: 30144956 PMCID: PMC6657019 DOI: 10.1016/j.jhep.2018.06.024] [Citation(s) in RCA: 513] [Impact Index Per Article: 102.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 06/28/2018] [Indexed: 12/11/2022]
Abstract
A frequent complication in liver cirrhosis is malnutrition, which is associated with the progression of liver failure, and with a higher rate of complications including infections, hepatic encephalopathy and ascites. In recent years, the rising prevalence of obesity has led to an increase in the number of cirrhosis cases related to non-alcoholic steatohepatitis. Malnutrition, obesity and sarcopenic obesity may worsen the prognosis of patients with liver cirrhosis and lower their survival. Nutritional monitoring and intervention is therefore crucial in chronic liver disease. These Clinical Practice Guidelines review the present knowledge in the field of nutrition in chronic liver disease and promote further research on this topic. Screening, assessment and principles of nutritional management are examined, with recommendations provided in specific settings such as hepatic encephalopathy, cirrhotic patients with bone disease, patients undergoing liver surgery or transplantation and critically ill cirrhotic patients.
Collapse
|
28
|
Abstract
AIM Acute post liver transplant (LT) phase is characterized by hypermetabolism and increased nutrient requirements. This study aimed to provide the cardinal data on nutrition progression in the management of acute post-LT patients. METHODS This exploratory study recruited 54 adult acute post-LT recipients. The information regarding patient stay, weight status, biochemical parameters, and route of feeding was gathered. Recipients' dietary and nutrient intake was computed by 24-h dietary recall method. RESULTS The data exhibited a significant trend of lower hemoglobin, platelet, and albumin levels and increased bilirubin (T), alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transferase levels (P < 0.05). In acute post-LT patients, a significant decrease in weight status (P < 0.001*) was observed. The recipients' information on daily nutrition progression showed significantly lower intake of calorie, protein, fats, calcium (P < 0.05) and lower percentage adequacy of other nutrients as compared to the recommended guidelines. The energy and protein intake from the parenteral route of feeding significantly decreased and that of through oral route significantly increased (P < 0.05) from postoperative day (POD) 2 to POD 9 and POD 12. CONCLUSION There are scant data on nutrition management in acute post-LT phase. The present study provides the framework for the formulation of continuous, patient-centric, aggressive nutrition management interventions for acute post-LT recipients.
Collapse
Affiliation(s)
- Neha Bakshi
- Department of Food and Nutrition, Lady Irwin College, University of Delhi, New Delhi, India
| | - Kalyani Singh
- Department of Food and Nutrition, Lady Irwin College, University of Delhi, New Delhi, India
| |
Collapse
|
29
|
Oh TK, Jo J, Oh AY. Perioperative Serum Calcium and Phosphorus Levels are Associated with Hospital Costs and Length of Stay after Major Abdominal Surgery. J Clin Med 2018; 7:jcm7100299. [PMID: 30249011 PMCID: PMC6210672 DOI: 10.3390/jcm7100299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 09/18/2018] [Accepted: 09/21/2018] [Indexed: 02/01/2023] Open
Abstract
This study aimed to identify an association between serum calcium (Ca) and phosphate (P) levels, tested during the pre- and postoperative period, with hospital costs and length of hospital stay (LOS) of patients who underwent major abdominal surgery. This retrospective cohort study analyzed the medical records of patients who underwent major abdominal surgery. A total of 3893 patients were included in the analysis, and multivariable linear regression analysis was performed. For a 1 mg/dL increase in preoperative Ca, total hospital costs decreased by 3997.9 dollars (coefficient: −3997.9, 95% confidence interval (CI): −4900.5, −30,953; p-value < 0.01), and for a 1 mg/dL increase in postoperative P, total hospital costs decreased by 702.5 dollars (coefficient: −702.5, 95% CI: −1274.5, −67.3; p-value = 0.03). Furthermore, for a 1 mg/dL increase in preoperative Ca, LOS decreased by 2.9 days (coefficient: −2.9, 95% CI: −3.7, −2.1; p-value < 0.01). For a 1 mg/dL increase in postoperative P, LOS decreased by 3.4 days (coefficient: −3.4, 95% CI: −4.2, −2.6; p-value < 0.01). This study suggested preoperative Ca and postoperative P could be useful indicators for the reduction of hospital costs and decrease in LOS from the perspective of enhanced recovery after surgery.
Collapse
Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea.
| | - Jihoon Jo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea.
| | - Ah-Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University, Seoul 03080, Korea.
| |
Collapse
|
30
|
Value of Preoperative Modified Body Mass Index in Predicting Postoperative 1-Year Mortality. Sci Rep 2018; 8:4614. [PMID: 29545522 PMCID: PMC5854572 DOI: 10.1038/s41598-018-22886-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/02/2018] [Indexed: 12/21/2022] Open
Abstract
Serum albumin and conventional BMI (cBMI) are commonly used indices of malnutrition status. Because cBMI does not reflect fluid accumulation, modified body mass index (mBMI, serum albumin × cBMI) is a more accurate measure of malnutrition status. This study investigated the association between preoperative mBMI and postoperative 1-year mortality, in comparison with serum albumin and cBMI. Medical records of 80,969 adult patients who underwent surgical procedures in a tertiary care hospital between 1 January, 2011 and 31 December, 2015 were retrospectively reviewed. Postoperative 1-year mortality increased with reduction in cBMI, mBMI, and albumin separately (P < 0.001). When considering interaction between cBMI and albumin, albumin was the only significant factor of postoperative 1-year mortality [odds ratio: 0.377, 95% confidence interval (0.245–0.579), P < 0.001], while cBMI or interaction (cBMI * albumin) was not significant (P > 0.05). Adjusted area under the curve (AUC) was highest (0.885) in the overall model (cBMI + albumin + cBMI * albumin); adjusted AUC between mBMI and albumin did not differ significantly (P = 0.558). Low albumin is the strongest independent predictor of postoperative 1-year mortality among the three variables (albumin, cBMI, mBMI). Adding cBMI to albumin does not increase the validity of the AUC of albumin.
Collapse
|
31
|
Abstract
As the cirrhosis progresses, development of complication like ascites, hepatic encephalopathy, variceal bleeding, kidney dysfunction, and hepatocellular carcinoma signify increasing risk of short term mortality. Malnutrition and muscle wasting (sarcopenia) is yet other complications that negatively impact survival, quality of life, and response to stressors, such as infection and surgery in patients with cirrhosis. Conventionally, these are not routinely looked for, because nutritional assessment can be a difficult especially if there is associated fluid retention and/or obesity. Patients with cirrhosis may have a combination of loss of skeletal muscle and gain of adipose tissue, culminating in the condition of "sarcopenic obesity." Sarcopenia in cirrhotic patients has been associated with increased mortality, sepsis complications, hyperammonemia, overt hepatic encephalopathy, and increased length of stay after liver transplantation. Assessment of muscles with cross-sectional imaging studies has become an attractive index of nutritional status evaluation in cirrhosis, as sarcopenia, the major component of malnutrition, is primarily responsible for the adverse clinical consequences seen in patients with liver disease. Cirrhosis is a state of accelerated starvation, with increased gluconeogenesis that requires amino acid diversion from other metabolic functions. Protein homeostasis is disturbed in cirrhosis due to several factors such as hyperammonemia, hormonal, and cytokine abnormalities, physical inactivity and direct effects of ethanol and its metabolites. New approaches to manage sarcopenia are being evolved. Branched chain amino acid supplementation, Myostatin inhibitors, and mitochondrial protective agents are currently in various stages of evaluation in preclinical studies to prevent and reverse sarcopenia, in cirrhosis.
Collapse
Key Words
- (PG) SGA, patient-generated SGA
- AMPK, 5′ adenosine monophosphate-activated protein kinase
- ASPEN, American Society of Parenteral and Enteral Nutrition
- ATP, adenosine triphosphate
- Akt/PKB, serine/threonine-specific protein kinase B
- BIA, bio-electric impedance analysis
- BMC, bone mineral content
- BMI, body mass index
- CT, computed tomography
- DDLT, deceased donor liver transplantation
- DRM, disease-related malnutrition
- DXA, dual X-ray absorptiometry
- ESPEN, European Society of Parenteral and Enteral Nutrition
- FFI, Fried Frailty Index
- FFM, fat free mass
- FFMI, fat free mass index
- FM, fat mass
- HE, hepatic encephalopathy
- LDLT, living donor liver transplant
- LST, lean soft tissue
- MAC, mid arm circumference
- MAMC, mid arm muscle circumference
- MELD, model for end-stage liver disease
- MNA, Mini Nutritional Assessment
- MRI, magnetic resonance imaging
- NASH, non-alcoholic steatohepatitis
- PCM, protein-calorie nalnutrition
- REE, resting energy expenditure
- RQ, respiratory quotient (or RQ or respiratory coefficient)
- SGA, Subjective Global Assessment
- SMI, Skeletal Muscle Index
- SPPB, Short Physical Performance Battery
- TIPS, trans jugular intrahepatic portocaval shunts
- TNF, tumour necrosis factor
- TSF, triceps skin fild thickness
- WHO, World Health Organisation
- YPA, total psoas area
- aKG, alfa keto glutarate
- cirrhosis
- mTORC1, mammalian target of rapamycin complex 1
- nutrition
Collapse
|
32
|
Mazurak VC, Tandon P, Montano-Loza AJ. Nutrition and the transplant candidate. Liver Transpl 2017; 23:1451-1464. [PMID: 29072825 DOI: 10.1002/lt.24848] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/07/2017] [Accepted: 08/01/2017] [Indexed: 02/07/2023]
Abstract
Cirrhosis is the most common indication for liver transplantation (LT) worldwide. Malnutrition is present in at least two-thirds of patients with cirrhosis awaiting LT. It negatively impacts survival, quality of life, and the ability to respond to stressors, such as infection and surgery. Muscle wasting or sarcopenia is the most objective feature of chronic protein malnutrition in cirrhosis, and this condition is associated with increased morbidity and mortality before and after LT. In addition to its objectivity, muscularity assessment with cross-sectional imaging studies is a useful marker of nutritional status in LT candidates, as sarcopenia reflects a chronic decline in the general physical condition, rather than acute severity of the liver disease. Despite the high prevalence and important prognostic role, malnutrition and sarcopenia are frequently overlooked because standards for nutritional assessment are lacking and challenges such as fluid retention and obesity are prevalent. In this review, current diagnostic methods to evaluate malnutrition, including muscle abnormalities in cirrhosis, are discussed and current knowledge regarding the incidence and clinical impact of malnutrition in cirrhosis and its impact after LT are presented. Existing and potential novel therapeutic strategies for malnutrition in cirrhosis are also discussed, emphasizing the treatment of muscle wasting in the LT candidate in an effort to improve survival while waiting for LT and to reduce morbidity and mortality after LT.Liver Transplantation 23 1451-1464 2017 AASLD.
Collapse
Affiliation(s)
| | - Puneeta Tandon
- Gastroenterology and Liver Unit, University of Alberta Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Aldo J Montano-Loza
- Gastroenterology and Liver Unit, University of Alberta Hospital, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
33
|
Nutritional status using subjective global assessment independently predicts outcome of patients waiting for living donor liver transplant. Indian J Gastroenterol 2017; 36:275-281. [PMID: 28856568 DOI: 10.1007/s12664-017-0779-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/22/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Malnutrition is an important risk factor for adverse outcomes in patients awaiting liver transplant. Living donor liver transplant, being an elective procedure, allows nutritional rehabilitation and optimization of these patients before transplant. AIM This paper aimed to evaluate the outcome of end-stage liver disease (ESLD) patients with various degrees of malnutrition waiting for living donor liver transplant. METHODS Nutritional status was assessed using subjective global assessment (SGA) in patients who were evaluated for a liver transplant at our center from January 2015 to September 2015. All the data were collected prospectively. Predictive factors for mortality were analyzed using logistic regression and survival was obtained using Kaplan-Meier curves. RESULTS One hundred and seventeen patients were grouped based on their nutrition status into normal, mild-moderate, and severe malnutrition. The groups were comparable in terms of age, sex, etiology of liver disease except alcoholic liver disease. Graft recipient weight ratio was comparable among groups. There was no significant difference in hospital stay. However, severe malnourished patients had higher incidence of sepsis (p=0.005) and death due to sepsis (p=0.01). Nutritional status was the only independent predictor of mortality on multivariate analysis. CONCLUSION Nutritional status measured with SGA independently predicts short-term outcome of ESLD patients waiting and after living donor liver transplant.
Collapse
|
34
|
Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale R, Waitzberg DL, Bischoff SC, Singer P. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017; 36:623-650. [DOI: 10.1016/j.clnu.2017.02.013] [Citation(s) in RCA: 939] [Impact Index Per Article: 134.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 02/07/2023]
|
35
|
Hand grip strength: A reliable, reproducible, cost-effective tool to assess the nutritional status and outcomes of cirrhotics awaiting liver transplant. Clin Nutr ESPEN 2017. [DOI: 10.1016/j.clnesp.2017.01.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
36
|
Abstract
The rates of morbidity and mortality after liver transplantation are related to the degree of malnutrition. Because malnutrition is prevalent among liver transplant recipients, nutrition care practitioners must be aggressive in providing nutrition support to these patients in the perioperative period. Postoperative tube feeding (TF) has been studied for its role in improving short-term posttransplant outcomes. This paper evaluates published research that studied postoperative TF in liver transplant recipients; the methodology and outcomes are reviewed and drawbacks of these studies are considered. Case studies of liver transplant patients who received postoperative TF illustrate the variability of patient profiles and posttransplant complications that influence the provision and duration of posttransplant TF.
Collapse
Affiliation(s)
- Jeanette M Hasse
- Baylor Institute of Transplantation, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246, USA.
| |
Collapse
|
37
|
Electromagnetic-Guided Bedside Placement of Nasoenteral Feeding Tubes by Nurses Is Non-Inferior to Endoscopic Placement by Gastroenterologists: A Multicenter Randomized Controlled Trial. Am J Gastroenterol 2016; 111:1123-32. [PMID: 27272012 DOI: 10.1038/ajg.2016.224] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 05/02/2016] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Electromagnetic (EM)-guided bedside placement of nasoenteral feeding tubes by nurses may improve efficiency and reduce patient discomfort and costs compared with endoscopic placement by gastroenterologists. However, evidence supporting this task shift from gastroenterologists to nurses is limited. We aimed to compare the effectiveness of EM-guided and endoscopic nasoenteral feeding tube placement. METHODS We performed a multicenter randomized controlled non-inferiority trial in 154 adult patients who required nasoenteral feeding and were admitted to gastrointestinal surgical wards in five Dutch hospitals. Patients were randomly assigned (1:1) to undergo EM-guided or endoscopic nasoenteral feeding tube placement. The primary end point was the need for reinsertion of the feeding tube (e.g., after failed initial placement or owing to tube-related complications) with a prespecified non-inferiority margin of 10%. RESULTS Reinsertion was required in 29 (36%) of the 80 patients in the EM-guided group and 31 (42%) of the 74 patients in the endoscopy group (absolute risk difference -6%, upper limit of one-sided 95% confidence interval 7%; P for non-inferiority=0.022). No differences were noted in success and complication rates. In the EM-guided group, there was a reduced time to start of feeding (424 vs. 535 min, P=0.001). Although the level of discomfort was higher in the EM-guided group (Visual Analog Scale (VAS) 3.9 vs. 2.0, P=0.009), EM-guided placement received higher recommendation scores (VAS 8.2 vs. 5.5, P=0.008). CONCLUSIONS EM-guided bedside placement of nasoenteral feeding tubes by nurses was non-inferior to endoscopic placement by gastroenterologists in surgical patients and may be considered the preferred technique for nasoenteral feeding tube placement.
Collapse
|
38
|
Bakshi N, Singh K. Nutrition assessment and its effect on various clinical variables among patients undergoing liver transplant. Hepatobiliary Surg Nutr 2016; 5:358-71. [PMID: 27500148 PMCID: PMC4960422 DOI: 10.21037/hbsn.2016.03.09] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 03/09/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Malnutrition is highly prevalent in patients undergoing liver transplantation and has been associated to various clinical variables and outcome of the surgery. METHODS We recruited 54 adult patients undergoing living donor liver transplant (LT) as study sample. Nutrition assessment was performed by body mass index (BMI), BMI for ascites, albumin, subjective global assessment (SGA) and anthropometry [mid upper arm circumference (MUAC), mid arm muscle circumference (MAMC), and triceps skin-fold (TSF)], Hand Grip strength, and phase angle of the body. Prevalence and comparison of malnutrition was performed with various clinical variables: aetiology, Child Turcotte Pugh scores and model for end stage liver disease (ESLD) grades, degree of ascites, blood product usage, blood loss during the surgery, mortality, days [intensive care unit (ICU), Ventilator and Hospital], and Bio-impedance analysis [weight, fat mass, fat free mass (FFM), muscle mass and body fat%]. RESULTS Assessment of nutrition status represents a major challenge because of complications like fluid retention, hypoalbuminemia and hypoproteinemia. Different nutrition assessment tools show great disparity in the level of malnutrition among ESLD patients. In the present study recipient nutrition status evaluation by different nutrition assessment tools used showed malnutrition ranging from 3.7% to 100%. BMI and anthropometric measurements showed lower prevalence of malnutrition than phase angle and SGA whereas hand grip strength showed 100% malnutrition. Agreement among nutrition assessment methods showed moderate agreement (κ=0.444) of SGA with phase angle of the body. Malnutrition by different assessment tools was significantly associated to various clinical variables except MELD and days (ICU, Ventilator and Hospital). SGA was significantly (P<0.05) associated to majority of the clinical variables like aetiology, child Turcotte Pugh grades, degree of ascites, blood product usage, blood loss during the surgery, BIA (fat mass, FFM, muscle mass and body fat%). CONCLUSIONS The different nutrition assessment tools showed great variability of results. SGA showed moderate agreement with phase angle of the body and was associated with various clinical and prognostic variables of liver transplantation.
Collapse
Affiliation(s)
- Neha Bakshi
- Department of Foods and Nutrition, Lady Irwin College, University of Delhi, New Delhi 110001, India
| | - Kalyani Singh
- Department of Foods and Nutrition, Lady Irwin College, University of Delhi, New Delhi 110001, India
| |
Collapse
|
39
|
Abstract
OPINION STATEMENT Most widely recognized complications in cirrhotic patients include ascites, hepatic encephalopathy, variceal bleeding, kidney dysfunction, and hepatocellular carcinoma; however, malnutrition and muscle wasting (sarcopenia) constitute common complications which negatively impact survival, quality of life, and response to stressors, such as infection and surgery in patients with cirrhosis. Despite the important role that malnutrition and sarcopenia play in the prognosis of patients with cirrhosis, they are frequently overlooked, in part because nutritional assessment can be a difficult task in patients with cirrhosis due to fluid retention and/or overweight. Moreover, patients with cirrhosis may develop simultaneous loss of skeletal muscle and gain of adipose tissue, culminating in the condition of "sarcopenic obesity." In addition, muscle depletion is characterized by both a reduction in muscle size and increased proportion of intermuscular and intramuscular fat-denominated "myosteatosis." Sarcopenia in cirrhotic patients has been associated with increased mortality, sepsis complications, hyperammonemia, overt hepatic encephalopathy, and increased length of stay after liver transplantation. Muscularity assessment with cross-sectional imaging studies has become an attractive index of nutritional status evaluation in cirrhosis, as sarcopenia reflects a chronic detriment in general physical condition, rather than acute severity of the liver disease. In this review, we discuss the current diagnostic methods to evaluate malnutrition and muscle abnormalities in cirrhosis and also analyze the current knowledge regarding incidence and clinical impact of malnutrition and muscle abnormalities in cirrhosis and their impact after liver transplantation. We also discuss existing and potential novel therapeutic strategies for malnutrition in cirrhosis, emphasizing the recognition of sarcopenia in cirrhosis in an effort to improve survival and reduce morbidity related to cirrhosis. Finally, we analyze new studies including sarcopenia with the MELD score that seems to allow better prediction of mortality among cirrhotic patients waiting for liver transplantation.
Collapse
Affiliation(s)
- Ragesh B Thandassery
- From the Division of Gastroenterology and Liver Unit, University of Alberta Hospital, Zeidler Ledcor Centre, 130 University Campus, Edmonton, AB, T6G 2X8, Canada
| | - Aldo J Montano-Loza
- From the Division of Gastroenterology and Liver Unit, University of Alberta Hospital, Zeidler Ledcor Centre, 130 University Campus, Edmonton, AB, T6G 2X8, Canada.
| |
Collapse
|
40
|
Toshima T, Shirabe K, Kurihara T, Itoh S, Harimoto N, Ikegami T, Yoshizumi T, Kawanaka H, Ikeda T, Maehara Y. Profile of plasma amino acids values as a predictor of sepsis in patients following living donor liver transplantation: Special reference to sarcopenia and postoperative early nutrition. Hepatol Res 2015; 45:1170-7. [PMID: 25586674 DOI: 10.1111/hepr.12484] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/06/2015] [Accepted: 01/07/2015] [Indexed: 12/13/2022]
Abstract
AIM Sarcopenia is an independent predictor of mortality and sepsis after living donor liver transplantation (LDLT). However, the exact mechanisms by which sarcopenia affects poor prognosis or worse immunity against postoperative sepsis are unclear, particularly regarding muscular amino acid metabolism, and the authors aimed to identify the role of plasma amino acids in sarcopenia by retrospective study. METHODS The area of the psoas muscle in 228 recipients of LDLT was retrospectively measured by dynamic computed tomography. Additionally, plasma amino acid levels were measured both pre- and postoperatively. The impact of plasma amino acids for postoperative sepsis and the relationship between sarcopenia and early nutrition after LDLT were analyzed. RESULTS Among the plasma amino acids, only leucine, isoleucine and glutamine in patients with sarcopenia were significantly lower than those without sarcopenia (each, P < 0.05). Multivariate analysis identified the lower plasma glutamine levels as a risk factor of postoperative sepsis after LDLT (odds ratio 5.371, P = 0.002). In sarcopenia patients, plasma glutamine levels after LDLT were significantly decreased compared with before LDLT in patients both with and without postoperative early nutrition. However, in non-sarcopenia patients with early nutrition, plasma glutamine levels after LDLT were comparable with those before LDLT. CONCLUSION This is the first report to study the profile of plasma amino acid change before and after LDLT. Low preoperative glutamine values were an independent risk factor for predicting postoperative sepsis. The efficacy of postoperative early nutrition may prevent postoperative sepsis by improving glutamine levels.
Collapse
Affiliation(s)
- Takeo Toshima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Shirabe
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeshi Kurihara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinji Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Norifumi Harimoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toru Ikegami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hirofumi Kawanaka
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tetsuo Ikeda
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| |
Collapse
|
41
|
Silva M, Gomes S, Peixoto A, Torres-Ramalho P, Cardoso H, Azevedo R, Cunha C, Macedo G. Nutrition in Chronic Liver Disease. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2015; 22:268-276. [PMID: 28868418 PMCID: PMC5580118 DOI: 10.1016/j.jpge.2015.06.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/25/2015] [Indexed: 12/12/2022]
Abstract
Protein-calorie malnutrition is a transversal condition to all stages of chronic liver disease. Early recognition of micro or macronutrient deficiencies is essential, because the use of nutritional supplements reduces the risk of complications. The diet of patients with chronic liver disease is based on a standard diet with supplements addition as necessary. Restrictions may be harmful and should be individualized. Treatment management should aim to maintain an adequate protein and caloric intake and to correct nutrient deficiencies. The large majority of patients with grade I/II hepatic encephalopathy can tolerate a regular diet. Protein restriction can aggravate malnutrition and is not recommended, except in cases of hepatic encephalopathy unresponsive to optimized therapy.
Collapse
Affiliation(s)
- Marco Silva
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Sara Gomes
- General Practice Department, Unidade Saúde Familiar Alfena, Porto, Portugal
| | - Armando Peixoto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | | | - Hélder Cardoso
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Rosa Azevedo
- Nutrition Department, Centro Hospitalar São João, Porto, Portugal
| | - Carla Cunha
- Nutrition Department, Centro Hospitalar São João, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| |
Collapse
|
42
|
Moghadamyeghaneh Z, Hwang G, Hanna MH, Phelan MJ, Carmichael JC, Mills SD, Pigazzi A, Dolich MO, Stamos MJ. Even modest hypoalbuminemia affects outcomes of colorectal surgery patients. Am J Surg 2015; 210:276-84. [PMID: 25892597 DOI: 10.1016/j.amjsurg.2014.12.038] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 12/15/2014] [Accepted: 12/22/2014] [Indexed: 12/28/2022]
Abstract
BACKGROUND A small decrease in the serum albumin from the normal level is a common condition in preoperative laboratory tests of colorectal surgery patients; however, there is limited data examining these patients. We sought to identify outcomes of such patients. METHODS The National Surgical Quality Improvement Program database was used to evaluate all patients who had modest levels of hypoalbuminemia (3 ≤ serum albumin < 3.5 g/dL) before colorectal resection from 2005 to 2012. Multivariate analysis using logistic regression was performed to quantify complications associated with modest hypoalbuminemia. RESULTS A total of 108,898 patients undergoing colorectal resection were identified, of which 16,962 (15.6%) had modest levels of preoperative hypoalbuminemia. Postsurgical complications significantly associated (P < .05) with modest hypoalbuminemia were as follows: hospitalization more than 30 days (adjusted odds ratio [AOR], 1.77), deep vein thrombosis (AOR, 1.64), unplanned intubation (AOR, 1.42), ventilator dependency for more than 48 hours (AOR, 1.30), and wound disruption (AOR, 1.22). CONCLUSIONS Modest hypoalbuminemia is a common preoperative condition in patients undergoing colorectal resection. Our analysis demonstrates that modest hypoalbuminemia has associations with increased postoperative complications, especially pulmonary complications.
Collapse
Affiliation(s)
- Zhobin Moghadamyeghaneh
- Department of Surgery, School of Medicine, University of California, Irvine, 333 City Boulevard, West Suite 1600, Orange, CA, USA
| | - Grace Hwang
- Department of Surgery, School of Medicine, University of California, Irvine, 333 City Boulevard, West Suite 1600, Orange, CA, USA
| | - Mark H Hanna
- Department of Surgery, School of Medicine, University of California, Irvine, 333 City Boulevard, West Suite 1600, Orange, CA, USA
| | - Michael J Phelan
- Department of Statistics, University of California, Irvine, CA, USA
| | - Joseph C Carmichael
- Department of Surgery, School of Medicine, University of California, Irvine, 333 City Boulevard, West Suite 1600, Orange, CA, USA
| | - Steven D Mills
- Department of Surgery, School of Medicine, University of California, Irvine, 333 City Boulevard, West Suite 1600, Orange, CA, USA
| | - Alessio Pigazzi
- Department of Surgery, School of Medicine, University of California, Irvine, 333 City Boulevard, West Suite 1600, Orange, CA, USA
| | - Matthew O Dolich
- Department of Surgery, School of Medicine, University of California, Irvine, 333 City Boulevard, West Suite 1600, Orange, CA, USA
| | - Michael J Stamos
- Department of Surgery, School of Medicine, University of California, Irvine, 333 City Boulevard, West Suite 1600, Orange, CA, USA.
| |
Collapse
|
43
|
Gerritsen A, de Rooij T, Dijkgraaf MG, Busch OR, Bergman JJ, Ubbink DT, van Duijvendijk P, Erkelens GW, Molenaar IQ, Monkelbaan JF, Rosman C, Tan AC, Kruyt PM, Bac DJ, Mathus-Vliegen EM, Besselink MG. Electromagnetic guided bedside or endoscopic placement of nasoenteral feeding tubes in surgical patients (CORE trial): study protocol for a randomized controlled trial. Trials 2015; 16:119. [PMID: 25872782 PMCID: PMC4390000 DOI: 10.1186/s13063-015-0633-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 03/04/2015] [Indexed: 12/12/2022] Open
Abstract
Background Gastroparesis is common in surgical patients and frequently leads to the need for enteral tube feeding. Nasoenteral feeding tubes are usually placed endoscopically by gastroenterologists, but this procedure is relatively cumbersome for patients and labor-intensive for hospital staff. Electromagnetic (EM) guided bedside placement of nasoenteral feeding tubes by nurses may reduce patient discomfort, workload and costs, but randomized studies are lacking, especially in surgical patients. We hypothesize that EM guided bedside placement of nasoenteral feeding tubes is at least as effective as endoscopic placement in surgical patients, at lower costs. Methods/Design The CORE trial is an investigator-initiated, parallel-group, pragmatic, multicenter randomized controlled non-inferiority trial. A total of 154 patients admitted to gastrointestinal surgical wards in five hospitals, requiring nasoenteral feeding, will be randomly allocated to undergo EM guided or endoscopic nasoenteral feeding tube placement. Primary outcome is reinsertion of the feeding tube, defined as the insertion of an endoscope or tube in the nose/mouth and esophagus for (re)placement of the feeding tube (e.g. after failed initial placement or dislodgement or blockage of the tube). Secondary outcomes include patient-reported outcomes, costs and tube (placement) related complications. Discussion The CORE trial is designed to generate evidence on the effectiveness of EM guided placement of nasoenteral feeding tubes in surgical patients and the impact on costs as compared to endoscopic placement. The trial potentially offers a strong argument for wider implementation of this technique as method of choice for placement of nasoenteral feeding tubes. Trial registration Dutch Trial Register: NTR4420, date registered 5-feb-2014 Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0633-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Arja Gerritsen
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands. .,Department of Surgery, University Medical Center Utrecht, PO Box 85500, , 3508, GA, Utrecht, the Netherlands.
| | - Thijs de Rooij
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands.
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Center, PO Box 22660, 1100, DD, Amsterdam, the Netherlands.
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands.
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, PO Box 22660, 1100, DD, Amsterdam, the Netherlands.
| | - Dirk T Ubbink
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands.
| | - Peter van Duijvendijk
- Department of Surgery, Gelre Hospital, PO Box 9014, 7300, DS, Apeldoorn, the Netherlands.
| | - G Willemien Erkelens
- Department of Gastroenterology, Gelre Hospital, PO Box 9014, 7300, DS, Apeldoorn, the Netherlands.
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, , 3508, GA, Utrecht, the Netherlands.
| | - Jan F Monkelbaan
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands.
| | - Camiel Rosman
- Department of Surgery, Canisius Wilhelmina Hospital, PO Box 9015, 6500, GS, Nijmegen, the Netherlands.
| | - Adriaan C Tan
- Department of Gastroenterology, Canisius Wilhelmina Hospital, PO Box 9015, 6500, GS, Nijmegen, the Netherlands.
| | - Philip M Kruyt
- Department of Surgery, Hospital Gelderse Vallei, PO Box 9025, 6710, HN, Ede, the Netherlands.
| | - Dirk Jan Bac
- Department of Gastroenterology, Hospital Gelderse Vallei, PO Box 9025, 6710, HN, Ede, the Netherlands.
| | - Elisabeth M Mathus-Vliegen
- Department of Gastroenterology and Hepatology, Academic Medical Center, PO Box 22660, 1100, DD, Amsterdam, the Netherlands.
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands.
| |
Collapse
|
44
|
Bémeur C, Butterworth RF. Reprint of: Nutrition in the Management of Cirrhosis and its Neurological Complications. J Clin Exp Hepatol 2015; 5:S131-40. [PMID: 26041952 PMCID: PMC4442848 DOI: 10.1016/j.jceh.2015.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 05/19/2013] [Indexed: 12/12/2022] Open
Abstract
Malnutrition is a common feature of chronic liver diseases that is often associated with a poor prognosis including worsening of clinical outcome, neuropsychiatric complications as well as outcome following liver transplantation. Nutritional assessment in patients with cirrhosis is challenging owing to confounding factors related to liver failure. The objectives of nutritional intervention in cirrhotic patients are the support of liver regeneration, the prevention or correction of specific nutritional deficiencies and the prevention and/or treatment of the complications of liver disease per se and of liver transplantation. Nutritional recommendations target the optimal supply of adequate substrates related to requirements linked to energy, protein, carbohydrates, lipids, vitamins and minerals. Some issues relating to malnutrition in chronic liver disease remain to be addressed including the development of an appropriate well-validated nutritional assessment tool, the identification of mechanistic targets or therapy for sarcopenia, the development of nutritional recommendations for obese cirrhotic patients and liver-transplant recipients and the elucidation of the roles of vitamin A hepatotoxicity, as well as the impact of deficiencies in riboflavin and zinc on clinical outcomes. Early identification and treatment of malnutrition in chronic liver disease has the potential to lead to better disease outcome as well as prevention of the complications of chronic liver disease and improved transplant outcomes.
Collapse
Key Words
- AAAs, aromatic amino acids
- BCAAs, branched-chain amino acids
- BMI, body mass index
- CNS, central nervous system
- CONUT, controlling nutritional status
- HE, hepatic encephalopathy
- ISHEN, International Society for Hepatic Encephalopathy and Nitrogen metabolism
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steato-hepatitis
- PNI, prognostic nutritional index
- complications
- hepatic encephalopathy
- liver disease
- liver transplantation
- nutritional status
Collapse
Affiliation(s)
- Chantal Bémeur
- Département de nutrition, Faculté de médecine, Université de Montréal, Montréal, Canada
- Unité de recherche en sciences neurologiques, Hôpital Saint-Luc (CHUM), Université de Montréal, Montréal, Canada
| | - Roger F. Butterworth
- Unité de recherche en sciences neurologiques, Hôpital Saint-Luc (CHUM), Université de Montréal, Montréal, Canada
| |
Collapse
|
45
|
Plank LD, Mathur S, Gane EJ, Peng SL, Gillanders LK, McIlroy K, Chavez CP, Calder PC, McCall JL. Perioperative immunonutrition in patients undergoing liver transplantation: a randomized double-blind trial. Hepatology 2015; 61:639-47. [PMID: 25212278 DOI: 10.1002/hep.27433] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Accepted: 09/07/2014] [Indexed: 12/15/2022]
Abstract
UNLABELLED Preliminary work suggested that perioperative immunonutrition (IMN) enriched in n-3 fatty acids, arginine, and nucleotides may improve preoperative nutritional status, enhance postoperative recovery, and reduce postoperative infectious complications in patients undergoing liver transplantation (LT). The current study examined these outcomes in a double-blind, randomized, controlled trial. Patients wait-listed for LT (n = 120) were randomized to either supplemental (0.6 L/d) oral IMN or an isocaloric control (CON). Enteral IMN or CON was resumed postoperatively and continued for at least 5 days. The change in total body protein (TBP) measured by neutron activation from study entry until immediately prior to LT was the primary endpoint and TBP measurements were repeated 10, 30, 90, 180, and 360 days after LT. Infectious complications were recorded for the first 30 postoperative days. Nineteen patients died or were delisted prior to LT. Fifty-two IMN and 49 CON patients received supplemental nutrition for a median (range) 56 (0-480) and 65 (0-348) days, respectively. Preoperative changes in TBP were not significant (IMN: 0.06 ± 0.15 [SEM]; CON: 0.12 ± 0.10 kg). Compared to baseline, a 0.7 ± 0.2 kg loss of TBP was seen in both groups at 30 days after LT (P < 0.0001) and, at 360 days, TBP had not increased significantly (IMN: 0.08 ± 0.19 kg; CON: 0.26 ± 0.23 kg). Infectious complications occurred in 31 (60%) IMN and 28 (57%) CON patients (P = 0.84). The median (range) postoperative hospital stay was 10 (5-105) days for IMN and 10 (6-27) days for CON patients (P = 0.68). CONCLUSION In patients undergoing LT, perioperative IMN did not provide significant benefits in terms of preoperative nutritional status or postoperative outcome.
Collapse
Affiliation(s)
- Lindsay D Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Abstract
Liver transplantation (LT) is a major surgery performed on patients with end stage liver disease. Nutrition is an integral part of patient care, and protein-energy malnutrition is almost universally present in patients suffering from liver disease undergoing LT. Nutrition assessment of preliver transplant phase helps to make a good nutrition care plan for the patients. Nutrition status has been associated with various factors which are related to the success of liver transplant such as morbidity, mortality, and length of hospital stay. To assess the nutritional status of preliver transplant patients, combinations of nutrition assessment methods should be used like subjective global assessment, Anthropometry mid arm-muscle circumference, Bioelectrical impedance analysis (BIA) and handgrip strength.
Collapse
Affiliation(s)
- Neha Bakshi
- Lady Irwin College, Department of Foods and Nutrition, University of Delhi, New Delhi, India
| | - Kalyani Singh
- Lady Irwin College, Department of Foods and Nutrition, University of Delhi, New Delhi, India
| |
Collapse
|
47
|
Urano E, Yamanaka-Okumura H, Teramoto A, Sugihara K, Morine Y, Imura S, Utsunomiya T, Shimada M, Takeda E. Pre- and postoperative nutritional assessment and health-related quality of life in recipients of living donor liver transplantation. Hepatol Res 2014; 44:1102-9. [PMID: 24164744 DOI: 10.1111/hepr.12263] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 10/16/2013] [Accepted: 10/18/2013] [Indexed: 02/08/2023]
Abstract
AIM The nutritional state of living donor liver transplantation (LDLT) recipients is one of the most important factors affecting postoperative outcome. Although the assessment of health-related quality of life (HRQOL) is of increasing importance, few studies have examined this in conjunction with LDLT recipient nutritional state. METHODS Ten LDLT recipients with end-stage liver disease were recruited for this study. Measurements of energy expenditure, anthropometrics and laboratory data were performed before and 1, 6 and 12-24 months after LDLT. HRQOL was measured by using the 36-item Short-Form (SF-36) before and 1, 3, 6 and 12-24 months after LDLT. RESULTS The preoperative value of non-protein respiratory quotient (npRQ) was 0.796 ± 0.026 and it increased significantly after the operation. Serum non-esterified fatty acid (NEFA) levels were high in the preoperative state, but had significantly decreased 1 month after the operation. A negative correlation between npRQ and NEFA was observed throughout the study period. Cholinesterase and albumin levels improved to normal levels within 6 and 12-24 months, respectively. The recovery of the physical component summary of the SF-36 was observed after the improvement of all domains of laboratory data and energy metabolism based on the nutritional state. CONCLUSION This study demonstrated that the recovery of metabolic function, laboratory data and HRQOL in LDLT recipients are variable, and it took more than 6 months to normalize the liver protein synthetic capacity and physical HRQOL score periods. Therefore, long-term nutritional support is required in LDLT recipients.
Collapse
Affiliation(s)
- Eri Urano
- Department of Clinical Nutrition, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Vulcano DSB, Carvalhaes MADBL, Bakonyi Neto A. Evaluation of nutritional indicators and body composition in patients with advanced liver disease enrolled for liver transplantation. Acta Cir Bras 2014; 28:733-9. [PMID: 24114303 DOI: 10.1590/s0102-86502013001000008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 09/10/2013] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Malnutrition is prevalent in patients with advanced liver disease (LD) related to multifactorial causes. Fluid retention can underestimate the nutritional status based on anthropometric measures. We evaluated nutritional indicators and body composition (BC) in patients with liver cirrhosis and correlated them with LD severity. METHODS Forty three patients with LD enrolled for liver transplantation were evaluated by Anthropometric measures, subjective evaluation (Global Assessment of Nutritional Status - SGA) and biochemical indicators. Single-frequency electrical bioimpedance (SFE-BIA) was used to evaluate body composition (BC). It measured resistance (R), reactance (Xc) and the phase angle (PA). LD severity was estimated by Child-Pugh and Meld criteria (Model for End-Stage Liver Disease). RESULTS Child-Pugh index between patients was 7.11 ± 1.70 and Meld was 12.23 ± 4.22. Arm Circumference, Arm Muscle Circumference and Arm Muscle Area, SGA, hemoglobin, hematocrit and albumin showed better correlation with disease severity. Xc and PA showed correlation both with Meld and Child-Pugh score when BC were evaluated. PA was depleted in 55.8% of the patients. CONCLUSIONS Diagnosis of malnutrition varied according to the method. Global assessment of nutritional status showed better correlation with disease severity than with objective methods. Single-frequency electrical bioimpedance for body composition analysis in cirrhotic patients must be cautiously used; however, primary vectors seems to be valid and promising in clinical practice.
Collapse
|
49
|
Sun Y, Yang Z, Tan H. Perioperative nutritional support and fluid therapy in patients with liver diseases. Hepatobiliary Surg Nutr 2014; 3:140-8. [PMID: 25019075 DOI: 10.3978/j.issn.2304-3881.2014.04.05] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 03/31/2014] [Indexed: 12/13/2022]
Abstract
The prevalence of liver dysfunction and malnutrition is common among patients with obstructive jaundice or cirrhosis, the poor nutrition status in patients with indications for hepatic resection increases the risk of postoperative complications and/or mortality. Hepatic surgery significantly affects body's metabolism and environment. Therefore, it is very important for patients with liver diseases undergoing hepatic surgery to receive essential nutritional support and fluid therapy during perioperative period. There are several principles in nutritional support and fluid therapy that surgeons need to pay attention to, for example, time, nutritional approach, fluid volume, choice of fat emulsions and amino acids. Some issues, such as albumin and plasma application, choice of crystalloid and colloid, liver protective therapy, also need further attention.
Collapse
Affiliation(s)
- Yongliang Sun
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Zhiying Yang
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Haidong Tan
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| |
Collapse
|
50
|
Yosry A, Omran D, Said M, Fouad W, Fekry O. Impact of nutritional status of Egyptian patients with end-stage liver disease on their outcomes after living donor liver transplantation. J Dig Dis 2014; 15:321-6. [PMID: 24593282 DOI: 10.1111/1751-2980.12141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Malnutrition is prevalent among patients with end-stage liver disease (ESLD) awaiting liver transplantation. Our aim was to examine prospectively the impact of patients' nutritional status on their outcomes after living donor liver transplantation (LDLT). METHODS In all, 30 patients scheduled for LDLT were subjected to a preoperative nutritional status assessment through subjective global assessment (SGA), nutritional risk screening (NRS 2002) and anthropometric measurements. All patients were followed up for 3 months after LDLT for mortality, graft rejection, number of clinically significant infective episodes, time spent in hospital (ward and intensive care unit [ICU]) and graft failure or dysfunction. RESULTS All patients were nutritionally compromised (evaluated by SGA and NRS 2002), and were divided into two groups: moderately and severely malnourished. Compared with moderately malnourished patients, severely malnourished patients showed significant postoperative hyperbilirubinemia, higher number of infective episodes and longer ICU stay. Preoperative triceps skinfold and mid-arm circumference were negatively correlated with the number of infective episodes (r = -0.33, P = 0.03 and r = -0.377, P = 0.04, respectively). Moreover, skeletal muscle mass was negatively correlated with postoperative serum alanine aminotransferase level (r = -0.52, P = 0.003) and the number of postoperative infective episodes (r = -0.3, P = 0.04). CONCLUSION Poor nutritional status of Egyptian patients with ESLD negatively affects the patients' outcomes after LDLT.
Collapse
Affiliation(s)
- Ayman Yosry
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | | | | | | |
Collapse
|