Nutritional status: its influence on the outcome of patients undergoing liver transplantation

Background: Malnutrition is frequently present in case of end‐stage liver diseases, and in cirrhotic patients, a poor nutritional status is considered to be one of the predictive factors for increased morbidity and mortality rates after surgery. The impact of the recipients' malnutrition on the outcome of liver transplantation (LT) is still under debate and recent studies have shown controversial results. Patients and methods: We prospectively analysed the nutritional status of 38 consecutive patients undergoing LT in our University Hospital. Subjective global nutritional assessments (SGA) and anthropometry were used for the evaluation of the nutritional status. Energy expenditure, dietary intake and energy balance were also evaluated. After LT, multiple short‐term outcomes that could be influenced by the nutritional status, such as number of episodes of infections (bacterial, viral and fungal) until discharge from hospital, length of stay in intensive care unit (ICU), length of hospital stay and in‐hospital graft and patient's survival, were recorded. Results: Malnutrition was identified in 53% of cases according to the SGA. Pretransplant nutritional status, haemoglobin levels and disease severity were independently associated with the number of infection episodes during the hospital stay. The presence of malnutrition was the only independent risk factor for the length of stay in the ICU and the total number of days spent in hospital. Conclusion: The present data suggest that recipients' malnutrition should be taken into account as a factor that increases complications and costs after LT.     

Gastrointestinal symptoms in patients with liver cirrhosis: Associations with nutritional status and health-related quality of life

Objective. Gastrointestinal symptoms can lead to decreased food intake and thereby increased morbidity. There is a general lack of data on the prevalence of gastrointestinal symptoms and their potential association with malnutrition and health-related quality of life (QoL) in cirrhosis. Our aim was to prospectively evaluate gastrointestinal symptoms, malnutrition, and QoL in patients with cirrhosis. Material and methods. Two validated questionnaires were used to measure gastrointestinal symptoms (gastrointestinal symptom rating scale (GSRS)) and health-related QoL (SF-36) in 128 consecutive cirrhotics (mean age 57 years, Child-Pugh score 8.6, MELD score 13.2) at a tertiary referral center. The results were compared with those of controls from the general population. Nutritional status was assessed by anthropometry and estimation of recent weight change. Results. Compared to controls, cirrhotic patients showed higher gastrointestinal symptom severity (total GSRS score: 1.53, 95% CI 1.50–1.55 versus 2.21, 95% CI 2.04–2.38) and profound reductions in the SF-36 physical (47.0 95% CI 45.0–49.0 versus 37.9, 95% CI 35.7–40.1) and mental component summary scores (51.0 95% CI 49.0–53.0 versus 39.2 95% CI 36.7–41.6). There were no significant differences in any GSRS domain between patients with and those without malnutrition. Multivariate analysis showed that gastrointestinal symptom severity was associated with the Child-Pugh score (beta?=?0.10, r<0.05), daily lactulose use (beta?=?0.65, p<0.005), and the presence of gastrointestinal comorbidities (beta?=?0.51, p<0.05). Negative weight change (beta?=???0.72, p<0.05) and the SF-36 physical (beta?=???4.26, p<0.005) and mental (beta?=???4.53, p<0.005) summaries were independently related to gastrointestinal symptom severity. Conclusions. Patients with cirrhosis show increased severity of gastrointestinal symptoms, which are associated with recent weight loss and impaired health-related QoL. The severity of gastrointestinal symptoms seems to be related to the severity of cirrhosis.     

Comparison of three methods of nutritional assessment in liver cirrhosis: subjective global assessment, traditional nutritional parameters, and body composition analysis

Background Liver cirrhosis affects the results of many of the traditional techniques currently used to evaluate nutritional status. Our aim was to compare the traditional two-compartment model (subjective global assessment and anthropometry and blood tests) of nutritional assessment with a multicompartmental model (body composition analysis) in patients with cirrhosis. Methods Seventy-nine patients and 17 control subjects were studied. Subjective global assessment, anthropometry and blood tests, and body composition analysis were performed for each. The two most important compartments were body cell mass and total body fat. The subjects were classified by each method as well nourished or moderately or severely malnourished. Results Twenty-five patients (31.6%) were malnourished according to the subjective global assessment, 2 (6.3%) with Child's class A cirrhosis, 10 (34.5%) with class B, and 13 (72.2%) with class C, whereas 24 (30.4%) were malnourished according to the traditional model, 5 (15.6%) in the Child's A group, 8 (27.6%) in B, and 11 (61.1%) in C. According to the multicompartmental model, 48 patients (60.1%) were malnourished, 11 (34.4%) in Child's A, 20 (69%) in B, and 17 (94.4%) in C. The use of the multicompartmental model increased the prevalence of malnutrition by more than 60% in Child's classes A and B patients and by more than 20% in Child's class C patients. Conclusions Traditional nutritional assessment, although easier, underestimated the prevalence and severity of malnutrition in patients with cirrhosis. The underestimation was more pronounced in Child's class A and B patients.     

Assessing nutritional status in children with chronic liver disease

The metabolic changes compounded by anorexia associated with chronic liver disease adversely affect growth in children. In many cases, this requires the administration of artificial nutritional support. It is important in this group of patients that those who are becoming nutritionally depleted are identified quickly and in those receiving artificial nutritional support, the effectiveness is monitored. The current review is an examination of methods available to assess nutritional status. These include anthropometry, methods available in the laboratory and a selection of less commonly used methods undergoing evaluation at research level. A brief discussion accompanies each technique, outlining the limitations of its use in children with chronic liver disease. The review concludes with an outline of how nutritional status should be assessed in this group of children, and suggests further research.     

Liver transplant for 70 patients with end-stage liver diseases

Introduction Progress in immunosuppression, surgical techniques, and perioperative care has promoted orthotopic liver transplantation from an experimental procedure to an accepted clinical treatment. Liver transplantation is considered the standard therapeutic approach for end-stage liver disease[1-4] with a postoperative survival rate increasing to 80% in 5 5] years.[1, However, there are a wide range of possible postoperative complications of technical and medical origin.[6-9] Based on ortho…     

Nutritional assessments for ordinary medical care in patients with chronic liver disease

Aim: In patients with chronic liver disease who are at risk of malnutrition, simple and useful assessments for nutritional status should be established for ordinary medical care. The prognostic nutritional index (PNI) and controlling nutritional status (CONUT) are simple assessments constructed of only two or three laboratory data. We aimed to describe the potential of PNI and CONUT as a nutritional assessment tool in patients with chronic liver disease. Methods: We enrolled 165 patients, aged 18–85 years, with chronic liver disease. These patients were nutritionally assessed by PNI or CONUT, demonstrating the association with the severity of chronic liver disease or anthropometric values. Results: The value of PNI or CONUT was significantly associated with the severity of chronic liver disease (P < 0.001, respectively). In addition, the value of CONUT was significantly associated with all the anthropometric values such as body mass index (BMI, P < 0.05), mid‐arm circumference (AC, P < 0.001), mid‐arm muscle circumference (AMC, P < 0.001), and triceps skinfold thickness (TSF, P < 0.001), whereas the value of PNI was significantly associated with the values of AC (P < 0.01), AMC (P < 0.05) and TSF (P < 0.05). Approximately 80% of cirrhotic patients were assessed by PNI or CONUT to have obvious malnutrition. Conclusion: PNI and CONUT are potential tools for nutritional assessment in patients with chronic liver disease, especially for ordinary medical care, because of their simplicity.     

直接作用抗病毒药物治疗丙型肝炎肝硬化和肝移植术后丙型肝炎复发的初步临床观察

目的观察直接作用抗病毒药物(direct-acting antiviral agents,DAAs)治疗丙型肝炎(丙肝)肝硬化和肝移植术后丙肝复发的安全性和临床效果。方法入组丙肝肝硬化7例(5例失代偿)和肝移植术后丙肝复发7例(移植后时间6~44个月,中位时间17个月),年龄26~69岁(中位年龄55岁),HCV RNA分型均为基因1b型,HCV RNA载量为6.90×104~4.34×107IU/ml。DAAs治疗方案为索菲布韦(sofosbuvir)+息米普韦(simeprevir)(3例)和harvoni(sofosbuvir+ledipasvir)(11例),疗程12周。治疗过程中观察HCV RNA、肝功能、安全性指标及不良反应。结果除1例肝移植术后患者4周时HCV RNA为5.60×10 IU/ml,其余患者均获快速病毒学应答,HCV RNA最快5 d低于检测值下限。所有患者均获得治疗结束时病毒学应答和持续病毒学应答,ALT和AST下降,ALB水平升高。移植术后患者他克莫司血药浓度未见明显变化。不良反应轻,主要为头痛(1例)、乏力(2例)和关节痛(1例)。结论 DAAs治疗丙肝肝硬化和肝移植术后丙肝复发安全性好,疗效肯定。对失代偿期丙肝肝硬化的远期疗效待观察。     

Changes in nutritional status after liver transplantation

Chronic liver disease has an important effect on nutritional status, and malnourishment is almost universally present in patients with end-stage liver disease who undergo liver transplantation. During recent decades, a trend has been reported that shows an increase in number of patients with end-stage liver disease and obesity in developed countries. The importance of carefully assessing the nutritional status during the work-up of patients who are candidates for liver replacement is widely recognised. Cirrhotic patients with depleted lean body mass (sarcopenia) and fat deposits have an increased surgical risk; malnutrition may further impact morbidity, mortality and costs in the post-transplantation setting. After transplantation and liver function is restored, many metabolic alterations are corrected, dietary intake is progressively normalised, and lifestyle changes may improve physical activity. Few studies have examined the modifications in body composition that occur in liver recipients. During the first 12 mo, the fat mass progressively increases in those patients who had previously depleted body mass, and the muscle mass recovery is subtle and non-significant by the end of the first year. In some patients, unregulated weight gain may lead to obesity and may promote metabolic disorders in the long term. Careful monitoring of nutritional changes will help identify the patients who are at risk for malnutrition or over-weight after liver transplantation. Physical and nutritional interventions must be investigated to evaluate their potential beneficial effect on body composition and muscle function after liver transplantation.     

酒精性肝硬化不同体质患者治疗前后营养状况评价

目的：通过对酒精性肝硬化患者中的湿热体质、血瘀体质两种主要体质类型进行中西医结合治疗,判断同种治疗方法对酒精性肝硬化不同体质营养状况的改善情况。方法：通过计算136例酒精性肝硬化患者《中医体质量表》得分情况,统计酒精性肝硬化患者136例中医体质分布,分析其中主要的体质类型即湿热体质、血瘀体质患者的营养状况,包括测定体重指数、三头肌皮褶厚度（triceps skin fold, TSF）、上臂肌围（mid-arm muscle circumference, MAMC）及上臂围（ mid-arm circumference , MAC）、血液白蛋白、淋巴细胞总数,对数据结果进行统计分析,比较其差异,均予以黄连解毒汤为主方进行中西医结合治疗,分析治疗前后营养状况差异情况。结果：酒精性肝硬化出现频率较高的中医体质为湿热体质、血瘀体质,经相同的中西医结合治疗后,湿热体质与血瘀体质部分营养状况有所改善,其差异具有统计学意义。结论：尽管同为酒精性肝硬化,但患者因为体质状态的不同（湿热体质状态;血瘀体质状态）,经相同的治疗后,其营养状况的改善也有所不同,其差异具有统计学意义,表明辨识体质进行更有针对性的个体化治疗有助于提高治疗效果。     

Factors associated with the development of persistently depressed cardiac output during the first year after cardiac transplantation

The purpose of this study was to determine factors associated with the development of a persistently depressed cardiac output during the first year after cardiac transplantation. With this aim in mind, the records of 133 consecutive patients undergoing orthotopic cardiac transplantation and surviving for ≥1 year after transplantation were reviewed. For each patient, the mean cardiac index for each of the 3-month periods, 0-3, 4-6, 7-9, and 10-12 months after transplantation was calculated. of the 133 patients, 19 (14%) had a mean cardiac index < 2.41/min/m² during ≥3 of these 3-month periods. The pre- and post-transplantation clinical, immunologic, and hemodynamic data of these 19 patients (study group) were compared with the remaining 114 patients (control group). Compared with the control group, the patients in the study group were older (56±5 vs. 46±15 years; p = 0.0001), more frequently had ischemic heart disease as the original diagnosis (58 vs. 37%; p < 0.05), had a lower preoperative cardiac index (1.91 ± 0.53 vs. 2.71 ± 1.0 1/min/m²; p = 0.0001), more frequently did not receive perioperative anti-T cell therapy (47 vs. 25%; p=0.046), and had a greater median number of infections during the first year after transplantation (5 vs. 3; p = 0.027). However, only one factor—a low preoperative cardiac index—emerged as an independent predictor of the development of a persistently depressed cardiac index during the first year after transplantation. Of note, mean systemic vascular resistance was higher in the study group than in the control group at every 3-month period following cardiac transplantation. One possible although largely speculative explanation of the latter observation is that heart transplantation does not entirely reverse the neurohumoral abnormalities of chronic heart failure. Furthermore, this persistently elevated systemic vascular resistance may impact negatively on long-term allograft function.     

Assessment of nutritional status of patients with hepatitis C virus-related liver cirrhosis

Aim: Nutrition support for patients with liver cirrhosis, such as late evening snacks and branched-chain amino acids, has been demonstrated to be effective. However, the assessment of the malnutrition of liver cirrhosis is still a problem. The aim of this study was to assess the nutritional status of patients with liver cirrhosis due to hepatitis C virus by six methods and to test the sensitivity and specificity of these methods. Methods: In total, 86 patients with liver cirrhosis due to hepatitis C virus were assessed for nutritional status by triceps skinfold thickness (TSF), arm muscle circumference (AMC), subjective global assessment (SGA), nutritional risk index (NRI), Maastricht index (MI), and instant nutritional assessment (INA). Results: Malnutrition was found in 11 (12.8%) patients by TSF, 15 (17.4%) by AMC, 22 (25.6%) by SGA, 52 (60.5%) by the NRI, 66 (76.7%) by the MI, and in 54 (62.8%) by INA. The MI detected malnutrition at a significantly higher rate compared with the other five methods. Sixty-two patients were diagnosed as malnourished by the combined index, which defines the patients as malnourished when any two of the NRI, MI, and INA also define them as malnourished. The misclassification rate compared with the combined indexes was significantly lower in the MI (4.7%) than in any of the TSF (59.3%), AMC (59.3%), SGA (46.5%), NRI (16.3%), and INA (14.0%). Conclusion: The MI was the best single score to identify the patients who had malnutrition, including early stage, and may benefit from nutrition support.     

Factors influencing survival at one year in patients with nonbiliary hepatic parenchymal cirrhosis

Transplantation may be considered for patients with advanced cirrhosis, however, adequate criteria for evaluating survival in those patients are ill-defined. The aim of the present study was to select, among several clinical and functional variables those that could best predict survival at one year. The data collected from 91 consecutive patients with parenchymal cirrhosis hospitalized in our center from February 1984 to January 1986 were subjected to stepwise logistic regression analysis. Death occurring during the first year following entry into the study was considered as a failure. During that period, there were no censored patients. Of 19 variables that entered into the analysis, only two were significant (P<0.01): presence (1: moderate; 2: severe) or absence (0) of ascites (A) and breath test (BT: % aminopyrine activity of administered dose at 2 hr). The logistic equation was: In (P/1 –P):–1.95 A+1.64 BT–0.393, where Prepresented the probability of survival at one year. For each patient, Pwas calculated according to his Aand BTvalues. Using a 0.7 probability cut-point to separate success from failure, 93% (70/75) of successes, 81% (13/16) of failures, and 91% (83/91) of both successes and failures could be correctly predicted. Predictive equations like the present preliminary one can be used in the future to better assess the risk of mortality in patients with parenchymal cirrhosis in whom liver transplantation is considered.     

Orthotopic liver transplantation in a patient with severe haemophilia A and with advanced liver cirrhosis

A patient with severe haemophilia A underwent orthotopic liver transplantation because of changes correlated to end-stage liver cirrhosis due to hepatitis B, C and D infection. Replacement therapy was carried out for 4 days and the clinical course was uneventful. At the time of reporting the patient has a normal working life. FVIII plasma concentration is normal. The indirect hyperbilirubinaemia may be related to the Gilbert's anomaly of the donor.     

Idiopathic extensive peliosis hepatis treated with liver transplantation

A 50-year-old Danish man, who neither had wasting disease nor was taking steroid-containing drugs, complained of abdominal distension, due to a markedly enlarged liver. Percutaneous needle biopsies were taken from the liver, and the findings gave suspicion of a neoplastic tumor. Because of reduced liver function and treatment-resistant ascites, he underwent liver transplantation without a definite preoperative diagnosis. The resected liver weighed 2900?g, and almost all of the parenchyma was destroyed and replaced by multicystic blood-filled spaces, diagnosed as extensive peliosis hepatis complicating liver cirrhosis. Extensive peliosis with liver cirrhosis is a rare condition. Only two cases, caused by contraceptives and treated by liver transplantation, are reported in the English-language literature. We could find no cause other than alcohol abuse lasting several years in this patient, and classified the present case as idiopathic extensive peliosis hepatis. Although scarce subjective findings and misleading liver biopsies made an exact diagnosis difficult, an orthotopic liver transplantation was the only treatment for such complicated peliosis hepatis.     

Ohio solid organ transplantation consortium criteria for liver transplantation in patients with alcoholic liver disease

AIM To evaluate risk of recidivism on a case-by-case basis.METHODS From our center's liver transplant program,we selected patients with alcoholic liver disease who were listed for transplant based on Ohio Solid Organ Transplantation Consortium(OSOTC) exception criteria.They were considered to have either a low or medium risk of recidivism,and had at least one or three or more months of abstinence,respectively.They were matched based on gender,age,and Model for End-Stage Liver Disease(MELD) score to controls with alcohol-induced cirrhosis from Organ Procurement and Transplant Network data.RESULTS Thirty six patients with alcoholic liver disease were approved for listing based on OSOTC exception criteria and were matched to 72 controls.Nineteen patients(53%) with a median [Inter-quartile range(IQR)] MELD score of 24(13) received transplant and were followed for a median of 3.4 years.They were matched to 38 controls with a median(IQR) MELD score of 25(9).At one and five years,cumulative survival rates(± standard error) were 90% ± 7% and 92% ± 5% and 73% ± 12% and 77% ± 8% in patients and controls,respectively(Log-rank test,P = 0.837).Four(21%) patients resumed drinking by last follow-up visit.CONCLUSION Compared to traditional criteria for assessment of risk of recidivism,a careful selection process with more flexibility to evaluate eligibility on a case-by-case basis can lead to similar survival rates after transplantation.