The impact of nutrition on cirrhotic patients awaiting liver transplantation

Effect of Immunonutrition on the Liver Function Status of End-Stage Liver Disease Patients Waiting/Referred for Liver Transplant: A Randomized Controlled Trial

Background Malnutrition and liver dysfunction are commonly observed in patients with chronic liver disease. With the current surge in liver diseases, prompt nutritional planning will ensure the well-being of patients during the waiting period and will improve the clinical outcomes following liver transplantation (LT). We conducted this study to monitor the effect of immunonutrition on liver function parameters among end-stage liver disease (ESLD) patients referred for LT. Methodology In this randomized controlled trial, 144 ESLD patients who met the inclusion criteria were randomly enrolled into control (CON) and intervention (INT) groups after obtaining informed consent. Three patients were lost to follow-up due to the COVID-19 lockdown. The INT group (n = 69) was provided with 100 g of immunonutrient and the CON group (n = 72) was provided with supervised diet advice. Liver function test (LFT) parameters such as total protein, albumin, total bilirubin, direct bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, and prothrombin time/international normalized ratio before and after therapy at one month were checked in both groups. Results The majority of patients with the disease were males (83.3% in the CON group vs 76.8% in the INT group), having alcoholism as the etiology in both groups with 45.8% in the CON group and 56.5% in the INT group. The comparison of LFT parameters among ESLD patients during pre and post-therapy between the control and immunonutrition groups did not show any statistically significant difference in the LFT parameters between the INT and CON groups both at baseline and at one month. Conclusions The impact of immunonutrition on ESLD patients awaiting LT compared to supervised diet advice did not significantly improve liver function. The liver disease itself profoundly affects the level of nutrition; hence, nutritional assessment and early nutritional interventions can be instituted to improve clinical outcomes.

Renal dysfunction independently predicts muscle mass loss in patients following liver transplantation

BACKGROUND: Liver transplantation (LT) is the only curative treatment for cirrhosis. However, the presence of complications can impact outcomes following LT. Sarcopenia, or muscle mass loss, is highly prevalent in patients with cirrhosis and is associated with longer hospitalization stays and a higher infection rate post-surgery. We aimed to identify patients at higher risk of early sarcopenia post-LT. METHODS: This retrospective study included 79 cirrhotic patients who underwent LT. Muscle mass was evaluated using the third lumbar spine vertebra skeletal muscle mass index (SMI) and sarcopenia was defined using established cut-off values. Computerized tomography (CT) scans performed within six-month peri-operative period (three months pre- and post-LT) were included in the study. Complications and comorbidities were collected and correlated to SMI post-LT and predictive models for SMI post-LT were constructed. RESULTS: The overall prevalence of sarcopenia was 46% and 62% before and after LT, respectively. Newly developed sarcopenia was found in 42% of patients. Post-LT sarcopenia was associated with longer hospital stays (54±37 vs 29±10 days, p = 0.002), higher number of infection (3±1 vs 1±2, p = 0.027), and greater number of complications (5±2 vs 3±2, p <0.001) compared to absence of sarcopenia. Multivariate analyses showed that the SMI post-LT was independently associated with pre-LT renal function markers, the glomerular filtration rate (GFR) and creatinine (Model 1, GFR: β = 0.33; 95% CI = 0.04–0.17; p = 0.003; Model 2, Creatinine: β = –0.29; 95% CI = –0.10 to –0.02; p = 0.009). CONCLUSIONS: The present study highlights the potential role of renal dysfunction in the development and persistence of sarcopenia after LT.

Clinical Nutrition and Human Rights. An International Position Paper

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political, and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Clinical nutrition and human rights. An international position paper

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Impact of Liver and Pancreas Diseases on Nutritional Status

Liver and pancreatic diseases have significant consequences on nutritional status, with direct effects on clinical outcomes, survival, and quality of life. Maintaining and preserving an adequate nutritional status is crucial and should be one of the goals of patients with liver or pancreatic disease. Thus, the nutritional status of such patients should be systematically assessed at follow-up. Recently, great progress has been made in this direction, and the relevant pathophysiological mechanisms have been better established. While the spectrum of these diseases is wide, and the mechanisms of the onset of malnutrition are numerous and interrelated, clinical and nutritional manifestations are common. The main consequences include an impaired dietary intake, altered macro and micronutrient metabolism, energy metabolism disturbances, an increase in energy expenditure, nutrient malabsorption, sarcopenia, and osteopathy. In this review, we summarize the factors contributing to malnutrition, and the effects on nutritional status and clinical outcomes of liver and pancreatic diseases. We explain the current knowledge on how to assess malnutrition and the efficacy of nutritional interventions in these settings.

The impact of L-branched-chain amino acids and L-leucine on malnutrition, sarcopenia, and other outcomes in patients with chronic liver disease

INTRODUCTION

Metabolic and hormonal disorders resulting from chronic liver diseases culminate in increased proteolysis and decreased protein synthesis, which contributes to the development and progression of malnutrition and, consequently, sarcopenia. Nutritional management of sarcopenia in liver cirrhosis is a continuously evolving field and data on essential amino acid supplementation in chronic liver diseases is scarce.

AREAS COVERED

This review encompasses the current literature on oral amino acids supplementation in patients with chronic liver disease or patients with liver cirrhosis to try to elucidate the possible effects of L-branched-chain amino acids and isolated L-leucine as a therapeutic approach to malnutrition and sarcopenia.

EXPERT COMMENTARY

To ensure an optimal nutritional status and to reduce sarcopenia, it is necessary to assess nutritional status in all patients with liver cirrhosis and to apply nutritional interventions accordingly. The supply of calories, proteins, and essential amino acids is necessary for the maintenance of muscle mass and function. Although supplementation of L-branched-chain amino acids plays an important role in liver disease, L-leucine has been described as the main amino acid involved in protein turnover, reducing proteolysis, and stimulating protein synthesis.

Comparing the effects of whey and casein supplementation on nutritional status and immune parameters in patients with chronic liver disease: a randomised double-blind controlled trial

Protein supplementation may be beneficial for patients with chronic liver disease (CLD). This study compared the effects of whey protein isolate (WP) and casein (CA) supplementation on nutritional status and immune parameters of CLD patients who were randomly assigned to take 20 g of WP or CA twice per d as a supplement for 15 d. Body composition, muscle functionality and plasmatic immunomarkers were assessed before and after supplementation. Patients were also classified according to the model for end-stage liver disease (MELD) into less (MELD < 15) and more (MELD ≥ 15) severe disease groups. Malnutrition, determined by the Subjective Global Assessment at baseline, was observed in 57·4 % and 54·2 % of patients in the WP and CA groups, respectively (P = 0·649). Protein intake was lower at baseline in the WP group than in the CA group (P = 0·035), with no difference after supplementation (P = 0·410). Both the WP and CA MELD < 15 groups increased protein intake after supplementation according to the intragroup analysis. No differences were observed in body composition, muscle functionality, most plasma cytokines (TNF, IL-6, IL-1β and interferon-γ), immunomodulatory proteins (sTNFR1, sTNFR2, brain-derived neurotrophic factor and glial cell line-derived neurotrophic factor) or immunomodulatory hormones (adiponectin, insulin and leptin) after supplementation in the WP groups at the two assessed moments. WP supplementation increased the levels of interferon-γ-induced protein-10/CXCL10 (P = 0·022), eotaxin-1/CCL11 (P = 0·031) and monocyte chemoattractant protein-1/CCL2 (P = 0·018) and decreased IL-5 (P = 0·027), including among those in the MELD ≥ 15 group, for whom IL-10 was also increased (P = 0·008). Thus, WP consumption by patients with CLD impacted the immunomodulatory responses when compared with CA with no impact on nutritional status.

Secondary sclerosing cholangitis in critically ill patients has a poor outcome but lower tumour incidence than primary sclerosing cholangitis

BACKGROUND

Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is an emerging disease with grim prognosis.

OBJECTIVE

Our aim was the analysis of prognostic factors, long-term outcome and risk of tumour development in SSC-CIP compared with primary sclerosing cholangitis (PSC) patients.

METHODS

Retrospective analysis between 2008 and 2018.

RESULTS

One hundred and eleven patients with SSC-CIP and 408 PSC patients were identified. Median orthotopic liver transplantation (OLT)-free survival was 16 months for SSC-CIP and 147 months for PSC (p < 0.001). OLT was performed in 18/111 SSC-CIP compared with 166/408 PSC patients (p < 0.001). Malignant tumours were detected in 17.9% of PSC patients (73/408) compared with 2.7% (3/111) in SSC-CIP (p < 0.001). In multivariate Cox regression analysis low levels of C-reactive protein (hazard ratio 4.687 (95% confidence interval (CI) 1.144-19.199, p = 0.032) were significantly associated with a prolonged survival whereas higher age (hazard ratio 0.488 (95% CI 0.23-1.038), p = 0.062) showed a trend for shorter survival in SSC-CIP. For PSC malignancies (hazard ratio 0.42 (95% CI 0.313-0.575), p < 0.001) and higher age (hazard ratio 0.709 (95% CI 0.544-0.922), p = 0.01) were associated with a shorter OLT-free survival.

CONCLUSION

SSC-CIP is characterized by acute onset of liver disease and poor prognosis but with lower tumour incidence compared with PSC.

Influence of gut microbiota and intestinal barrier on enterogenic infection after liver transplantation

Liver transplantation is currently a standard therapy for patients with end-stage liver diseases and hepatocellular carcinoma. Given that liver transplantation has undergone a thriving development in these decades, the survival rates after liver transplantation have markedly improved as a result of the critical advancement in surgical techniques, immunosuppressive therapies, and post-operative care. However, infection remains a fatal complication after liver transplantation surgery. In particular, enterogenic infection represents a major complication in liver transplant recipients. This article gives an overview of infection cases after liver transplantation and focuses on the discussion of enterogenic infection in terms of its pathophysiology, risk factor, outcome, and treatment.

Nutrition Screening vs Nutrition Assessment: What's the Difference?

Screening and assessment imply different processes, with the former indicating risk factors for a deprived nutrition condition and the latter providing the nutrition diagnosis. Both should be routinely performed at hospital admission according to recommended guidelines; however, this is not the reality worldwide, and undernutrition remains highly prevalent in the hospital setting. Therefore, the objective of the current review is to delve into the principles leading to nutrition status deficiencies and how they should be addressed by screening and assessment. A critical appraisal for the reasons associated with the misunderstanding between screening and assessing is proposed without further discussing the many available screening tools while approaching some of the assessment instruments.

Nutrition and the transplant candidate

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.

Liver transplantation: need, indications, patient selection and pre-transplant care

Chronic or acute liver failure and primary liver cancers can be effectively managed with liver transplantation. The range of indications for liver transplantation is increasing but there is a mismatch between the numbers of available donations and current needs. Specific criteria for listing patients exist but, at minimum, the predicted mortality without transplantation must exceed that with transplantation, coupled with a 50% predicted 5-year survival following liver transplantation. The risk posed by liver disease must be weighed against the risk of liver transplantation, considering the patient's comorbidities, age, nutritional status and behavioural factors in a complex assessment process. This article reviews current UK practice in the selection and care of patients being assessed for liver transplantation.

Probiotics for people with hepatic encephalopathy

BACKGROUND

Hepatic encephalopathy is a disorder of brain function as a result of liver failure or portosystemic shunt or both. Both hepatic encephalopathy (clinically overt) and minimal hepatic encephalopathy (not clinically overt) significantly impair patient's quality of life and daily functioning, and represent a significant burden on healthcare resources. Probiotics are live micro-organisms, which when administered in adequate amounts, may confer a health benefit on the host.

OBJECTIVES

To determine the beneficial and harmful effects of probiotics in any dosage, compared with placebo or no intervention, or with any other treatment for people with any grade of acute or chronic hepatic encephalopathy. This review did not consider the primary prophylaxis of hepatic encephalopathy.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, conference proceedings, reference lists of included trials, and the World Health Organization International Clinical Trials Registry Platform until June 2016.

SELECTION CRITERIA

We included randomised clinical trials that compared probiotics in any dosage with placebo or no intervention, or with any other treatment in people with hepatic encephalopathy.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. We conducted random-effects model meta-analysis due to obvious heterogeneity of participants and interventions. We defined a P value of 0.05 or less as significant. We expressed dichotomous outcomes as risk ratio (RR) and continuous outcomes as mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included 21 trials with 1420 participants, of these, 14 were new trials. Fourteen trials compared a probiotic with placebo or no treatment, and seven trials compared a probiotic with lactulose. The trials used a variety of probiotics; the most commonly used group of probiotic was VSL#3, a proprietary name for a group of eight probiotics. Duration of administration ranged from 10 days to 180 days. Eight trials declared their funding source, of which six were independently funded and two were industry funded. The remaining 13 trials did not disclose their funding source. We classified 19 of the 21 trials at high risk of bias.We found no effect on all-cause mortality when probiotics were compared with placebo or no treatment (7 trials; 404 participants; RR 0.58, 95% CI 0.23 to 1.44; low-quality evidence). No-recovery (as measured by incomplete resolution of symptoms) was lower for participants treated with probiotic (10 trials; 574 participants; RR 0.67, 95% CI 0.56 to 0.79; moderate-quality evidence). Adverse events were lower for participants treated with probiotic than with no intervention when considering the development of overt hepatic encephalopathy (10 trials; 585 participants; RR 0.29, 95% CI 0.16 to 0.51; low-quality evidence), but effects on hospitalisation and change of/or withdrawal from treatment were uncertain (hospitalisation: 3 trials, 163 participants; RR 0.67, 95% CI 0.11 to 4.00; very low-quality evidence; change of/or withdrawal from treatment: 9 trials, 551 participants; RR 0.70, 95% CI 0.46 to 1.07; very low-quality evidence). Probiotics may slightly improve quality of life compared with no intervention (3 trials; 115 participants; results not meta-analysed; low-quality evidence). Plasma ammonia concentration was lower for participants treated with probiotic (10 trials; 705 participants; MD -8.29 μmol/L, 95% CI -13.17 to -3.41; low-quality evidence). There were no reports of septicaemia attributable to probiotic in any trial.When probiotics were compared with lactulose, the effects on all-cause mortality were uncertain (2 trials; 200 participants; RR 5.00, 95% CI 0.25 to 102.00; very low-quality evidence); lack of recovery (7 trials; 430 participants; RR 1.01, 95% CI 0.85 to 1.21; very low-quality evidence); adverse events considering the development of overt hepatic encephalopathy (6 trials; 420 participants; RR 1.17, 95% CI 0.63 to 2.17; very low-quality evidence); hospitalisation (1 trial; 80 participants; RR 0.33, 95% CI 0.04 to 3.07; very low-quality evidence); intolerance leading to discontinuation (3 trials; 220 participants; RR 0.35, 95% CI 0.08 to 1.43; very low-quality evidence); change of/or withdrawal from treatment (7 trials; 490 participants; RR 1.27, 95% CI 0.88 to 1.82; very low-quality evidence); quality of life (results not meta-analysed; 1 trial; 69 participants); and plasma ammonia concentration overall (6 trials; 325 participants; MD -2.93 μmol/L, 95% CI -9.36 to 3.50; very low-quality evidence). There were no reports of septicaemia attributable to probiotic in any trial.

AUTHORS' CONCLUSIONS

The majority of included trials suffered from a high risk of systematic error ('bias') and a high risk of random error ('play of chance'). Accordingly, we consider the evidence to be of low quality. Compared with placebo or no intervention, probiotics probably improve recovery and may lead to improvements in the development of overt hepatic encephalopathy, quality of life, and plasma ammonia concentrations, but probiotics may lead to little or no difference in mortality. Whether probiotics are better than lactulose for hepatic encephalopathy is uncertain because the quality of the available evidence is very low. High-quality randomised clinical trials with standardised outcome collection and data reporting are needed to further clarify the true efficacy of probiotics.

Enteral Nutrition in Chronic Liver Disease: Translating Evidence Into Practice

Malnutrition is prevalent in individuals with chronic liver disease and occurs as a result of inadequate nutrient intake, altered metabolism, and malabsorption. Although limited data show benefits of enteral nutrition (EN) in this population, patients with chronic liver disease often have inadequate oral intake and are potential candidates for EN. The goals of the EN, type and severity of liver disease, and access for EN will influence the decision to initiate EN. This paper summarizes EN studies in patients with liver disease and provides practical tips regarding patient selection, EN access, and EN formula choices. Two case studies illustrate the principles and challenges of providing EN to patients with cirrhosis. The paper concludes with suggested parameters for an EN feeding protocol and recommendations for future research.

Update on malnutrition assessment in patients with liver cirrhosis

Liver cirrhosis is the terminal stage of chronic hepatitis, often accompanied by protein-caloric malnutrition (PCM). Many factors may be at play causing an individual with liver cirrhosis to develop malnutrition. Malnutrition is regarded as the important prognostic factor of cirrhosis and is the contraindication to liver transplantation. However, in clinical practice, physicians and nurses often do not detect the presence of malnutrition fully in the population with cirrhosis, nor do they realize its damaging consequences. As a consequence, malnutrition is often overlooked. Given all these, this review focuses on several aspects of nutritional assessment, on the basis of the latest research reports, aiming at having a comprehensive and up-to-date understanding concerning malnutrition in cirrhosis, as well as giving medical providers instructions to perform a clinical nutritional assessment more perfectly.

Absolute lymphocyte count recovery at 1 month after transplantation predicts favorable outcomes of patients with hepatocellular carcinoma

BACKGROUND AND AIMS

Absolute lymphocyte count (ALC) and the recovery of ALC after treatment have been identified as a prognostic biomarker for several malignancies. In this study, we aimed to investigate the prognostic role of peritransplant ALC and ALC recovery after liver transplantation (LT) in hepatocellular carcinoma (HCC) patients.

METHODS

A total of 269 HCC patients undergoing LT were enrolled in our study. Clinicopathological data were retrospectively collected and reviewed. Peritransplant ALC and the change of ALC (2 weeks, 1 month, 3 months post-LT) were carefully monitored. All potential risk factors were analyzed by univariate and multivariate cox regression analysis.

RESULTS

Over a mean follow-up of 35.9 months, 120 recurrences and 89 deaths were recorded. In the multivariate analysis, HCC with ALC no recovery at 1 month after LT (P < 0.001), high pretransplant alpha fetoprotein (P = 0.010), total tumor size > 8 cm (P = 0.003), and beyond Milan criteria (P < 0.001) were four independent risk factors for HCC recurrence. For overall survival (OS) after LT, ALC no recovery at 1 month after LT (P = 0.003), total tumor size > 8 cm (P = 0.011), pretransplant albumin < 2.8 g/dL (P = 0.049), model of end-stage liver disease score > 15 (P = 0.017), and beyond Milan criteria (P = 0.001) were significantly related to poor OS. When subgroup analyses were performed according to the Milan criteria, the results showed that the recovery of ALC at 1 month after LT still indicated longer recurrence-free survival (RFS) (P < 0.001) and OS (P = 0.005) beyond Milan criteria as well as RFS (P < 0.001) within Milan criteria, but not OS (P = 0.157) within Milan criteria.

CONCLUSIONS

ALC recovery at 1 month after LT indicated favorable outcomes of HCC patients.

Peritransplant lymphopenia is a novel prognostic factor in recurrence of hepatocellular carcinoma after liver transplantation

BACKGROUND

Absolute lymphocyte count (ALC) is considered a surrogate marker for the level of immunosuppression and nutritional status of patients and a prognostic factor for survival and recurrence in several cancers. The aim of this study was to investigate the prognostic value of peritransplant ALC for the recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT).

METHODS

HCC patients who underwent LT between 2000 and 2010 were evaluated. Exclusion criteria were combined HCC and cholangiocarcinoma. Peritransplant ALCs (before LT and 2 weeks and 1 month after LT) were analyzed along with tumor, operative, and donor characteristics to identify risk factors for the recurrence of HCC.

RESULTS

HCC developed in 27 of the 173 LT patients investigated for risk factors (15.6%). The median time to recurrence was 1.14 years. Low ALCs before and after LT were associated with a higher recurrence rate in a continuous manner (before LT: hazard ratio=1.12, P=0.003; 2 weeks after LT: hazard ratio=1.14, P=0.008; 1 month after LT: hazard ratio=1.06, P=0.055) (increased risk per 100/μL down). On multivariate Cox regression analysis, peritransplant persistent lymphopenia (<1000/μL before LT and <500/μL at 2 weeks and 1 month after LT) was an independent risk factor for cancer recurrence (hazard ratio=7.05, P<0.001), along with tumor characteristics.

CONCLUSION

Peritransplant lymphopenia is a powerful prognostic factor for the recurrence of HCC after LT, which suggests that maintaining ALCs in LT patients might improve cancer outcome.

Negative energy balance secondary to inadequate dietary intake of patients on the waiting list for liver transplantation

OBJECTIVES

The aim of this study was to evaluate the energy balance (EB) of patients on the waiting list for liver transplantation, using total energy expenditure (TEE) assessment and total caloric intake (TCI).

METHODS

We analyzed nutrient adequacy and factors associated with it. EB was obtained by subtracting the TCI (obtained by 3-d food record) from TEE, which was measured as resting energy expenditure and physical activity factor calculation. Socioeconomic and clinical data also were evaluated. Univariate and multiple linear regressions were used (P < 0.05). Seventy-three patients were included.

RESULTS

The TEE was 2318.5 kcal, and the TCI was 1485.1 kcal, with 81.6% of patients presenting with negative EB. There was no significant association between TCI and socioeconomic variables, medications, and encephalopathy (P > 0.05). Women, less-educated patients, those with ascites, and those who were malnourished presented with lower TCI (P < 0.05). Severity of disease, by Child-Pugh and Model for End-Stage Liver Disease scores were associated with EB (P < 0.05). Child-Pugh remained significant after multivariate analyses. Energy inadequacy was observed in 91.8% of patients, and protein inadequacy in 72.6% of patients. Polyunsaturated fatty acid (64.4%) and monounsaturated fatty acid (91.8%) and fiber (94.5%) inadequacies also were high. The percentage of adequate intake was less than 10% for vitamins B5 and D, calcium, folic acid, and potassium, and higher percentages of adequate intake (>80%) were found for iron and vitamins B1 and B12. Moreover, 54.8% and 16.4% of the patients had excessive sodium and cholesterol intakes, respectively.

CONCLUSION

Negative EB was highly prevalent among patients on the waiting list for liver transplantation, and was associated with the severity of liver disease. Negative EB was primarily affected by low food intake. The food intake data were characterized by low overall energy and protein intake and inadequate composition of the patient's diet plan, which tended to be characterized by specific nutrient deficiencies and excesses.

Current status of research on enterogenic infection following liver transplantation

Since the introduction of the Milan criteria in 1996, liver transplantation has become a standard therapy for end-stage liver diseases and hepatocellular carcinoma. In recent years, liver transplantation has developed greatly. Survival rates after liver transplantation have markedly improved as a result of improved operative techniques, use of immunosuppressants, etc. But infection, especially enterogenic infection, is still the most disturbing complication in patients undergoing liver transplantation. This article gives an overview of infection after liver transplantation and focuses on the discussion of enterogenic infection in terms of its pathophysiology, risk factors, outcome, diagnosis and treatment.

Weight loss during cirrhosis is related to the etiology of liver disease

CONTEXT

Malnutrition is widely described in patients waiting for liver transplantation (LTx). However, risk factors associated with weight loss during liver disease have not yet been well studied.

OBJECTIVES

The aim of this study was to assess weight loss and its risk factors during liver disease and up to the first appointment after transplantation. Patients who underwent LTx were retrospectively assessed for weight loss during liver disease while on the waiting list for LTx. The usual weight of the patients before disease and their weight on the first outpatient appointment after transplant were considered. Demographic, socioeconomic, lifestyle and clinical variables were collected to assess risk factors using a linear regression analysis. We retrospectively evaluated 163 patients undergoing LTx between 1997 and 2008.

RESULTS

Patients lost in average 7.7 ± 12.4 kg while ill. Variables independently associated with weight loss by multiple linear regression analyses were as follows: former smoker (P = 0.03), greater body mass index (P<0.01), overweight before liver disease (P = 0.02) and indication for LTx (P = 0.01). Among these indications, patients with alcoholic cirrhosis had lost significantly more weight (P<0.01), and those with hepatitis C virus (P = 0.01) and autoimmune hepatitis (P = 0.02) had lost significantly less weight.

CONCLUSIONS

Patients experienced weight loss during liver disease independent of age, sex, schooling and income; however, the etiology of liver disease was related to weight loss.

Nutritional interventions for liver-transplanted patients

BACKGROUND

Malnutrition is a common problem for patients waiting for orthotopic liver transplantation and a risk factor for post-transplant morbidity. The decision to initiate enteral or parenteral nutrition, to which patients and at which time, is still debated. The effects of nutritional supplements given before or after liver transplantation, or both, still remains unclear.

OBJECTIVES

The aim of this review was to assess the beneficial and harmful effects of enteral and parenteral nutrition as well as oral nutritional supplements administered to patients before and after liver transplantation.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register (March 2012), the Cochrane Central Register of Controlled Trials (Issue 2 of 12, 2012) in The Cochrane Library, MEDLINE (January 1946 to March 2012), EMBASE (January 1974 to March 2012), Science Citation Index Expanded (January 1900 to March 2012), Social Science Citation Index (January 1961 to October 2010), and reference lists of articles. Manufacturers and experts in the field have also been contacted and relevant journals and conference proceedings were handsearched (from 1997 to October 2010).

SELECTION CRITERIA

Randomised clinical trials of parallel or cross-over design evaluating the beneficial or harmful effects of enteral or parenteral nutrition or oral nutritional supplements for patients before and after liver transplantation were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias of the trials and extracted data. Dichotomous data were reported as odds ratios (OR) and continuous data as mean differences (MD) along with their corresponding 95% confidence intervals (CI). Meta-analysis was not possible due to clinical heterogeneity of included interventions.

MAIN RESULTS

Thirteen trials met the inclusion criteria. Four publications did not report outcomes pre-defined in the review protocol, or other clinically relevant outcomes and additional data could not be obtained. Nine trials could provide data for the review. Most of the 13 included trials were small and at high risk of bias. Meta-analyses were not possible due to clinical heterogeneity of the interventions.No interventions that were likely to be beneficial were identified.For interventions of unknown effectiveness,postoperative enteral nutrition compared with postoperative parenteral nutrition seemed to have no beneficial or harmful effects on clinical outcomes. Parenteral nutrition containing protein, fat, carbohydrates, and branched-chain amino acids with or without alanyl-glutamine seemed to have no beneficial effect on the outcomes of one and three years survival when compared with a solution of 5% dextrose and normal saline. Enteral immunonutrition with Supportan® seemed to have no effect on occurrence of immunological rejection when compared with enteral nutrition with Fresubin®.There is weak evidence that, compared with standard dietary advice, adding a nutritional supplement to usual diet for patients during the waiting time for liver transplantation had an effect on clinical outcomes after liver transplantation. The combination of enteral nutrition plus parenteral nutrition plus glutamine-dipeptide seemed to be beneficial in reducing length of hospital stay after liver transplantation compared with standard parenteral nutrition (mean difference (MD) -12.20 days; 95% CI -20.20 to -4.00). There is weak evidence that the use of parenteral nutrition plus branched-chain amino acids had an effect on clinical outcomes compared with standard parenteral nutrition, but each was beneficial in reducing length of stay in intensive care unit compared to a standard glucose solution (MD -2.40; 95% CI -4.29 to -0.51 and MD -2.20 days; 95% CI -3.79 to -0.61). There is weak evidence that adding omega-3 fish oil to parenteral nutrition reduced the length of hospital stay after liver transplantation (mean difference -7.1 days; 95% CI -13.02 to -1.18) and the length of stay in intensive care unit after liver transplantation (MD -1.9 days; 95% CI -1.9 to -0.22).For interventions unlikely to be beneficial, there is a significant increased risk in acute rejections in malnourished patients with a history of encephalopathy and treated with the nutritional supplement Ensure® compared with usual diet only (MD 0.70 events per patient; 95% CI 0.08 to 1.32).

AUTHORS' CONCLUSIONS

We were unable to identify nutritional interventions for liver transplanted patients that seemed to offer convincing benefits. Further randomised clinical trials with low risk of bias and powerful sample sizes are needed.

Malnutrition in cirrhosis: contribution and consequences of sarcopenia on metabolic and clinical responses

Malnutrition is the most common, reversible complication of cirrhosis that adversely affects survival, response to other complications, and quality of life. Sarcopenia, or loss of skeletal muscle mass, and loss of adipose tissue and altered substrate use as a source of energy are the 2 major components of malnutrition in cirrhosis. Current therapies include high protein supplementation especially as a late evening snack. Exercise protocols have the potential of aggravating hyperammonemia and portal hypertension. Recent advances in understanding the molecular regulation of muscle mass has helped identify potential novel therapeutic targets including myostatin antagonists, and mTOR resistance.

Probiotics for patients with hepatic encephalopathy

BACKGROUND

Hepatic encephalopathy is a disorder of brain function as a result of liver failure and/or portosystemic shunt. Both hepatic encephalopathy (clinically overt) and minimal hepatic encephalopathy (not clinically overt) significantly impair patient's quality of life and daily functioning and represent a significant burden on health care resources. Probiotics are live microorganisms, which when administered in adequate amounts may confer a health benefit on the host.

OBJECTIVES

To quantify the beneficial and harmful effects of any probiotic in any dosage, compared with placebo or no intervention, or with any other treatment for patients with any grade of acute or chronic hepatic encephalopathy as assessed from randomised trials.

SEARCH METHODS

We searched the The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, conference proceedings, reference lists of included trials and the WHO international clinical trials registry until April 2011 registry platform to identify new and ongoing trials.

SELECTION CRITERIA

We included randomised trials that compared probiotics in any dosage with placebo or no intervention, or with any other treatment in patients with hepatic encephalopathy.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed the risk of bias of the included trials and extracted data on relevant outcomes, with differences resolved by consensus. We conducted random-effects model meta-analysis due to obvious heterogeneity of patients and interventions. A P value of 0.05 or less was defined as significant. Dichotomous outcomes are expressed as risk ratio (RR) and continuous outcomes as mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included seven trials of which 550 participants were randomised. Four of the seven trials compared a probiotic with placebo or no treatment in 245 participants, another trial compared a probiotic with lactulose in 40 participants , and the remaining two trials compared a probiotic with both placebo and lactulose in 265 participants. Each trial used different types of probiotics. Duration of administration of the experimental intervention varied from 10 days to 180 days. Two trials were industry funded, and five were unclear about origin of funding. All trials had high risk of bias. When probiotics were compared with no treatment, there was no significant difference in all-cause mortality (2 trials, 105 participants; 1/57 (2%) versus 1/48 (2%): RR 0.72; 95% CI 0.08 to 6.60), lack of recovery (4 trials, 206 participants; 54/107 (50%) versus 68/99 (69%): RR 0.72; 95% CI 0.49 to 1.05), adverse events (3 trials, 145 participants; 2/77 (3%) versus 6/68 (9%): RR 0.34; 95% CI 0.08 to 1.42), quality of life (1 trial, 20 participants contributed to the physical quality of life measurement, 20 participants contributed to the mental quality of life: MD Physical 0.00; 95% CI -5.47 to 5.47; MD Mental 4.00; 95% CI -1.82 to 9.82), or change of/or withdrawal from treatment (3 trials, 175 participants; 11/92 (12%) versus 7/83 (8%): RR 1.28; 95% CI 0.52 to 3.19). No trial reported sepsis or duration of hospital stay as an outcome. Plasma ammonia concentration was significantly lower for participants treated with probiotic at one month (3 trials, 226 participants: MD -2.99 μmol/L; 95% CI -5.70 to -0.29) but not at two months (3 trials, 181 participants: MD -1.82 μmol/L; 95% CI -14.04 to 10.41). Plasma ammonia decreased the most in the participants treated with probiotic at three months (1 trial, 73 participants: MD -6.79 μmol/L; 95% CI -10.39 to -3.19). When probiotics were compared with lactulose no trial reported all-cause mortality, quality of life, duration of hospital stay, or septicaemia. There were no significant differences in lack of recovery (3 trials, 173 participants; 47/87 (54%) versus 44/86 (51%): RR 1.05; 95% CI 0.75 to 1.47), adverse events (2 trials, 111 participants; 3/56 (5%) versus 6/55 (11%): RR 0.57; 95% CI 0.06 to 5.74), change of/or withdrawal from treatment at one month (3 trials, 190 participants; 8/95 (8%) versus 7/95 (7%): RR 1.10; 95% CI 0.40 to 3.03), plasma ammonia concentration (2 trials, 93 participants: MD -6.61 μmol/L; 95% CI -30.05 to 16.84), or change in plasma ammonia concentration (1 trial, 77 participants: MD 1.16 μmol/L; 95% CI -1.96 to 4.28).

AUTHORS' CONCLUSIONS

The trials we located suffered from a high risk of systematic errors ('bias') and high risk of random errors ('play of chance'). While probiotics appear to reduce plasma ammonia concentration when compared with placebo or no intervention, we are unable to conclude that probiotics are efficacious in altering clinically relevant outcomes. Demonstration of unequivocal efficacy is needed before probiotics can be endorsed as effective therapy for hepatic encephalopathy. Further randomised clinical trials are needed.