Nutritional evaluation in cirrhosis: Emphasis on the phase angle

Protein-calorie malnutrition(PCM) is a common condition in cirrhotic patients, leading to a worse prognosis, complications, poor quality of life and lower survival rates. Among ways of assessing nutritional status, there are anthropometric methods such as the evaluation of the triceps skinfold, the arm circumference, the arm muscle circumference and the body mass index, and nonanthropometric methods such as the subjective global assessment, the handgrip strength of non-dominant hand, and the bioelectrical impedance analysis(BIA). PCM is frequently under-diagnosed in clinical settings in patients with cirrhosis due to the limitations of nutritional evaluation methods in this population. BIA is a useful method, but cannot be indicated in patients with abnormal body composition. In these situations, the phase angle(PA) has been used, and can become an important tool in assessing nutritional status in any situation. The PA is superior to anthropometric methods and might be considered as a nutritional indicator in cirrhosis. The early characterization of the nutritional status in patients with cirrhosis means an early nutritional intervention, with a positive impact on patients' overall prognosis. Among the usually accepted methods for nutritional diagnosis, the PA provides information in a quick and objective manner.     

Nutrition in alcohol-related liver disease: Physiopathology and management

Malnutrition encompassing both macro-and micro-nutrient deficiency,remains one of the most frequent complications of alcohol-related liver disease(ArLD).Protein-energy malnutrition can cause significant complications including sarcopenia,frailty and immunodepression in cirrhotic patients.Malnutrition reduces patient's survival and negatively affects the quality of life of individuals with ArLD.Moreover,nutritional deficit increases the likelihood of hepatic decompensation in cirrhosis.Prompt recognition of at-risk individuals,early diagnosis and treatment of malnutrition remains a key component of ArLD management.In this review,we describe the pathophysiology of malnutrition in ArLD, review the screening tools available for nutritional assessment and discuss nutritional management strategies relevant to the different stages of ArLD,ranging from acute alcoholic hepatitis through to decompensated end stage liver disease.     

Nutritional assessment in patients with liver cirrhosis

Malnutrition is a liver cirrhosis complication affecting more than 20%-50% of patients. Although the term can refer to either nutrient deficiency or excess, it usually relates to undernutrition in cirrhosis settings. Frailty is defined as limited physical function due to muscle weakness, whereas sarcopenia is defined as muscle mass loss and an advanced malnutrition stage. The pathogenesis of malnutrition in liver cirrhosis is multifactorial, including decreased oral intake, maldigestion/malabsorption, physical inactivity, hyperammonemia, hypermetabolism, altered macronutrient metabolism and gut microbiome dysbiosis. Patients with chronic liver disease with a Body Mass Index of < 18.5 kg/m² and/or decompensated cirrhosis or Child-Pugh class C are at the highest risk of malnutrition. For patients at risk of malnutrition, a detailed nutritional assessment is required, typically including a history and physical examination, laboratory testing, global assessment tools and body composition testing. The latter can be done using anthropometry, cross-sectional imaging including computed tomography or magnetic resonance, bioelectrical impedance analysis and dual-energy X-ray absorptiometry. A multidisciplinary team should screen for and treat malnutrition in patients with cirrhosis. Malnutrition and sarcopenia are associated with an increased risk of complications and a poor prognosis in patients with liver cirrhosis; thus, it is critical to diagnose these conditions early and initiate the appropriate nutritional therapy. In this review, we describe the prevalence and pathogenesis of malnutrition in liver cirrhosis patients and discuss the best diagnostic approach to nutritional assessment for them.     

肝硬化患者营养不良、肌肉减少症及骨质疏松的防治

营养不良、肌肉减少症(肌少症)及骨质疏松是肝硬化患者常见的营养相关并发症,肌少症是营养不良的重要表现,而营养不良、肌少症又是骨质疏松发生的危险因素,三者相互关系密切,且都对肝硬化患者的临床结局和预后产生不良影响,故要及早发现,积极防治。营养物质摄入不足、代谢紊乱、激素水平异常、身体活动缺乏等促使肝硬化患者易出现营养不良、肌少症及骨质疏松。此外,肝病治疗常用药物如糖皮质激素、某些抗病毒药物等可能影响骨代谢,需引起临床关注。合理的营养干预、适当的运动和基础疾病的治疗是防治营养不良、肌少症及骨质疏松的基础。一些针对性治疗药物可有助于改善患者的上述营养相关并发症,但仍需进一步研究证实。     

Sarcopenia in the prognosis of cirrhosis: Going beyond the MELD score

Estimating the prognosis of patients with cirrhosis remains challenging, because the natural history of cirrhosis varies according to the cause, presence of portal hypertension, liver synthetic function, and the reversibility of underlying disease. Conventional prognostic scoring systems, including the Child-Turcotte-Pugh score or model for end-stage liver diseases are widely used; however, revised models have been introduced to improve prognostic performance. Although sarcopenia is one of the most common complications related to survival of patients with cirrhosis, the newly proposed prognostic models lack a nutritional status evaluation of patients. This is reflected by the lack of an optimal index for sarcopenia in terms of objectivity, reproducibility, practicality, and prognostic performance, and of a consensus definition for sarcopenia in patients with cirrhosis in whom ascites and edema may interfere with body composition analysis. Quantifying skeletal muscle mass using cross-sectional abdominal imaging is a promising tool for assessing sarcopenia. As radiological imaging provides direct visualization of body composition, it is useful to evaluate sarcopenia in patients with cirrhosis whose body mass index, anthropometric measurements, or biochemical markers are inaccurate on a nutritional assessment. Sarcopenia defined by cross-sectional imaging-based muscular assessment is prevalent and predicts mortality in patients with cirrhosis. Sarcopenia alone or in combination with conventional prognostic systems shows promise for a cirrhosis prognosis. Including an objective assessment of sarcopenia with conventional scores to optimize the outcome prediction for patients with cirrhosis needs further research.     

Nutritional Assessment and Management for Hospitalized Patients with Cirrhosis

Purpose of Review

The purpose of this review is to summarize recent knowledge on malnutrition and sarcopenia in liver cirrhosis with special focus on hospitalized cirrhotic patients. Assessment tools and treatment options are briefly discussed.

Recent Findings

During hospitalization, cirrhotic patients frequently deteriorate their nutritional status due to multiple factors. Evaluation of nutritional risk followed by nutritional assessment has been suggested in cirrhotic patients and may alert the need of special nutritional care in those hospitalized. Few recent studies, although in small series, proposed to ameliorate sarcopenia in cirrhotic patients by protein/calorie supplementation and also encouraging physical activity.

Summary

Malnutrition and sarcopenia are negative predictors of morbidity and mortality in hospitalized cirrhotic patients. When malnutrition is diagnosed, care should be taken to provide adequate nutritional support. Physical movement, whenever possible, has been suggested for prevention of muscle loss.

     

Nutrition and exercise in the management of liver cirrhosis

Liver cirrhosis (LC) patients often have protein-energy malnutrition (PEM) and decreased physical activity. These conditions often lead to sarcopenia, which is the loss of skeletal muscle volume and increased muscle weakness. Recent studies have demonstrated that PEM and sarcopenia are predictors for poor survival in LC patients. Nutrition and exercise management can improve PEM and sarcopenia in those patients. Nutrition management includes sufficient dietary intake and improved nutrient metabolism. With the current high prevalence of obesity, the number of obese LC patients has increased, and restriction of excessive caloric intake without the exacerbation of impaired nutrient metabolism is required for such patients. Branched chain amino acids are good candidates for supplemental nutrients for both obese and non-obese LC patients. Exercise management can increase skeletal muscle volume and strength and improve insulin resistance; however, nutritional status and LC complications should be assessed before an exercise management regimen is implemented in LC patients. The establishment of optimal exercise regimens for LC patients is currently required. In this review, we describe nutritional status and its clinical impact on the outcomes of LC patients and discuss general nutrition and exercise management in LC patients.     

Malnutrition in cirrhosis: More food for thought

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.     

肝硬化合并肌肉减少症的危险因素及其对临床结局的影响

目的研究肌肉减少症在肝硬化患者中的发生情况,探讨其危险因素及其对临床结局的影响。方法收集肝硬化住院患者199例,进行营养风险筛查、人体测量、血生物化学检查,根据体成分分析测得的四肢骨骼肌含量计算骨骼肌质量指数(ASMI),将患者分为肌肉减少症组和无肌肉减少症组,比较两组相关指标,筛选影响肌肉减少症发生的因素;随访48个月,比较两组生存、并发症发生情况。据资料不同分别采用t检验、χ2检验、Logistic回归分析进行统计学分析。结果肌肉减少症在肝硬化中的发生率为36.7%,在并发肝性脑病患者中最为多见(62.5%),其次是并发腹/胸水患者(37.6%)。有营养风险者肌肉减少症发生率明显高于无营养风险者(P<0.05),即使无营养风险者也有14.8%合并肌肉减少症。肌肉减少症组体质量指数(BMI)、上臂肌围、身体细胞量低于无肌肉减少症组(P<0.05),浮肿指数(ECW/TBW)高于后者(P<0.05)。多因素分析结果显示,年龄、性别、BMI、并发症肝性脑病是肝硬化合并肌肉减少症的主要影响因素(P<0.05)。随访期间肌肉减少症组病死率高于无肌肉减少症者(P<0.05),反复腹/胸水、肝性脑病、感染的发生率亦明显升高(P<0.05)。结论肌肉减少症是肝硬化患者营养不良的表现之一,使患者病死率、发生其他并发症的风险升高,对临床结局产生不良影响。老年、男性患者、BMI越低、并发肝性脑病,肌肉减少症发生风险越高。     

肝硬化肌肉减少症的发病机制及诊治现状

肌肉减少症是肝硬化营养不良的重要表现形式,已成为肝硬化患者不可忽视的并发症,与患者的生活质量、住院时间、并发症发生率及死亡率密切相关,且对肝移植预后有重要影响,因此,早期诊断及干预治疗对改善肝硬化患者预后极为重要。但目前国内外对于肌肉减少症的诊断标准还未达成共识。近年来随着对肌肉分子调控机制、肌肉生长相关激素、高氨血症介导的信号通路及肠道菌群作用的深入研究,肌肉减少症发生机制被逐渐认识。适当的营养干预、合理运动、降氨治疗、补充激素、分子靶向治疗等可能改善肝硬化患者肌肉质量,将是未来研究的重点。综述了近年来肝硬化肌肉减少症的相关研究,对其流行病学特点、发生机制、诊断及治疗进行简要阐述。     

Sarcopenia in chronic viral hepatitis: From concept to clinical relevance

Although the frequency of metabolic risk factors for cirrhosis and hepatocellular carcinoma (HCC) is increasing, chronic hepatitis B (CHB) and chronic hepatitis C (CHC) remain the most relevant risk factors for advanced liver disease worldwide. In addition to liver damage, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are associated with a myriad of extrahepatic manifestations including mixed cryoglobulinaemia, lymphoproliferative disorders, renal disease, insulin resistance, type 2 diabetes, sicca syndrome, rheumatoid arthritis-like polyarthritis, and autoantibody production. Recently, the list has grown to include sarcopenia. Loss of muscle mass or muscle function is a critical feature of malnutrition in cirrhotic patients and has been found in approximately 23.0%-60.0% of patients with advanced liver disease. Nonetheless, among published studies, there is significant heterogeneity in the aetiologies of hepatic diseases and measurement methods used to determine sarcopenia. In particular, the interaction between sarcopenia, CHB and CHC has not been completely clarified in a real-world setting. Sarcopenia can result from a complex and multifaceted virus-host-environment interplay in individuals chronically infected with HBV or HCV. Thus, in the present review, we provide an overview of the concept, prevalence, clinical relevance, and potential mechanisms of sarcopenia in patients with chronic viral hepatitis, with an emphasis on clinical outcomes, which have been associated with skeletal muscle loss in these patients. A comprehensive overview of sarcopenia in individuals chronically infected with HBV or HCV, independent of the stage of the liver disease, will reinforce the necessity of an integrated medical/nutritional/physical education approach in the daily clinical care of patients with CHB and CHC.     

Nutritional evaluation of the cirrhotic patient: an objective, subjective or multicompartmental approach?

BACKGROUND: Malnutrition due to liver disease is common and its assessment is difficult. The parameters of nutritional evaluation often used in clinical practice have limited use in cirrhotic patients. Many of the clinical signs of malnutrition are the result of the underlying hepatic disease which tends to confound and alter the nutritional diagnosis. AIM: To present a brief review of the different methods of nutritional evaluation together with their limitations and uses in cirrhotic patients. CONCLUSION: The multicompartmental approach for four compartments was shown to be considerably sensitive in the detection of malnutrition. However the ample use of this method is impaired due to technical difficulties and high costs. The handgrip strength appears to be a simple, cheap and effective alternative to detected malnutrition and risk of malnutrition in these patients. Is the most sensitive method and is able to predict a significant incidence of major complications in undernourished cirrhotic patients.     

Abnormalities of Lipoprotein Levels in Liver Cirrhosis: Clinical Relevance

Progressive lipoprotein impairment occurs in liver cirrhosis and is associated with increased morbidity and mortality. The present review aims to summarize the current evidence regarding the prognostic value of lipoprotein abnormalities in liver cirrhosis and to address the need of a better prognostic stratification of patients, including lipoprotein profile assessment. Low levels of lipoproteins are usual in cirrhosis. Much evidence supports the prognostic role of hypolipidemia in cirrhotic patients. In particular, hypocholesterolemia represents an independent predictor of survival in cirrhosis. In cirrhotic patients, lipoprotein impairment is associated with several complications: infections, malnutrition, adrenal function, and spur cell anemia. Alterations of liver function are associated with modifications of circulating lipids. Decreased levels of lipoproteins significantly impact the survival of cirrhotic patients and play an important role in the pathogenesis of some cirrhosis-related complications.     

Nutritional risk and malnutrition determination by anthropometry in cirrhotic children and adolescents

BACKGROUND: The malnutrition is a frequent finding in adults with cirrhosis, but the prevalence of nutritional risk and malnutrition is little known in pediatric patients. AIM: To evaluate through anthropometry the presence of nutritional risk and malnutrition in cirrhotic pediatric patients regularly attended at the Pediatric Gastroenterology Service of "Hospital de Clínicas" of Porto Alegre, RS, Brazil. METHODS: Cross-sectional study with 42 cirrhotic children and adolescents aged between 3 months and 18 years. The nutritional evaluation was made by the determination of the weight/age, height/age, body mass index and triceps skinfold thickness and arm muscle circumference measurements. Patients considered in nutritional risk were < or = -1,28 Z score which corresponds to < or = 10th percentile, and those under -2,0 Z and < or = 3th percentile were in malnutrition status. According to Child-Pugh criteria, 22 patients were classified as A (mild severity), 15 (moderate) B and 5 C (intense). RESULTS: The mean weight/age, height/age and body mass index Z scores were, respectively, - 0,38 +/- 1,4 SD, - 0,83 +/- 1,16 SD and 0,17 +/- 1,3 SD. Patients in nutritional risk were 3/42 (weight/age), 8/42 (height/age), 12/37 (triceps skinfold thickness), 9/37 (arm muscle circumference), 2/38 (body mass index); in malnutrition status were 6/42 (weight/age), 7/42 (height/age), 4/37 (triceps skinfold thickness) and 4/37 (arm muscle circumference) and 3/38 (body mass index). CONCLUSION: The prevalence of nutritional risk was 32.4% and chronic malnutrition was 16.7%. The index which better reflected the nutritional risk in these patients was triceps skinfold thickness. Chronic malnutrition status occurrence was greater in the height/age index.     

Malnutrition-related polyunsaturated fatty acid changes in plasma lipid fractions of cirrhotic patients.

Cirrhotic patients have both impaired liver function and nutritional derangement. In fact, the prevalence of protein-energy malnutrition (PEM) is very high in these patients. The aim of the present study was to elucidate whether the nutritional status in cirrhosis could be an additional factor that would affect levels of plasma lipids. Plasma lipid phosphorus, cholesterol, and triglycerides (TG), and fatty acid profiles in plasma and plasma fractions were determined in 50 healthy subjects and 92 patients with liver cirrhosis. The cirrhotic patients were prospectively included in three groups according to the result of nutritional assessment: group 1 (n = 38), acceptable nutritional status (including well-nourished and mildly malnourished patients); group 2 (n = 29), moderate PEM; and group 3 (n = 25), severe PEM. The main findings of this study were that the decrease in plasma cholesterol and linoleic, dihomo-gamma-linolenic, and arachidonic acid levels of cirrhotic patients was related to the degree of PEM. Cholesteryl esters (CE) appeared to be the most sensitive indicator of lipid changes in cirrhosis. We consider that the role of malnutrition in the changes observed for polyunsaturated fatty acid (PUFA) profiles in plasma lipids of cirrhotic patients may be of major importance, since severe malnourished subjects exhibited the lowest levels of those compounds. Dietary supplementation of both essential fatty acids (EFA) and long-chain PUFA in adequate amounts to the cirrhotic patient might be of importance in the management of the disease.     

Posttransplant Sarcopenia: An Underrecognized Early Consequence of Liver Transplantation

Liver transplantation is believed to reverse the clinical and metabolic abnormalities of cirrhosis. Reduced skeletal muscle mass or sarcopenia contributes to increased mortality and adverse consequences of cirrhosis. Failure of reversal of sarcopenia of cirrhosis after liver transplantation is not well recognized. Six temporally, geographically, and methodologically distinct follow-up studies in 304 cirrhotics reported conflicting data on changes in indirect measures of skeletal muscle mass after transplantation. Distinct measures of body composition but not skeletal muscle mass were used and did not focus on the clinical consequences of sarcopenia after transplantation. A number of studies reported an initial rapid postoperative loss of lean mass followed by incomplete recovery with a maximum follow-up of 2 years. Posttransplant sarcopenia may be responsible for metabolic syndrome and impaired quality of life after liver transplantation. Potential reasons for failure to reverse sarcopenia after liver transplantation include use of immunosuppressive agents [mammalian target of rapamycin (mTOR) and calcineurin inhibitors] that impair skeletal muscle growth and protein accretion. Repeated hospitalizations, posttransplant infections, and renal failure also contribute to posttransplant sarcopenia. Finally, recovery from muscle deconditioning is limited by lack of systematic nutritional and physical-activity-based interventions to improve muscle mass. Despite the compelling data on sarcopenia before liver transplantation, the impact of posttransplant sarcopenia on clinical outcomes is not known. There is a compelling need for studies to examine the mechanisms and consequences of sarcopenia post liver transplantation to permit development of therapies to prevent and reverse this disorder.     

Nutritional assessment in cirrhotic patients with hepatic encephalopathy

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

Neurological complications post-liver transplantation: impact of nutritional status

Nutritional status is significantly altered in patients with end-stage liver disease (cirrhosis). Malnutrition is a common complication of cirrhosis and is known to be associated with a greater risk of post-operative complications and mortality, especially following liver transplantation. Neurological complications occur frequently after transplant and the nature and extent of these complications may relate to nutritional deficits such as protein-calorie malnutrition as well as vitamin and micronutrient deficiencies. A consensus document from the International Society on Hepatic Encephalopathy and Nitrogen metabolism (ISHEN) has been established in order to address these concerns. Careful assessment of nutritional status followed by prompt treatment of nutritional deficits has the potential to impact on transplant outcome and, in particular, on post-transplant neurological disorders in patients with cirrhosis.     

Malnutrition in end stage liver disease: recommendations and nutritional support

Malnutrition has increasingly been acknowledged as an important prognostic factor which can influence the clinical outcome of patients suffering from end-stage liver disease (ESLD). Despite the fact that malnutrition is not included in the Child-Pugh classification, its presence should alert clinicians to the same extent as do other complications, such as ascites and hepatic encephalopathy. The pathophysiological mechanisms and the clinical conditions that drive cirrhotic patients to an ill-balanced metabolic state are multiple and they intertwine. Inadequate offer of nutrients, the hypermetabolic state in cirrhosis, the diminished synthetic capacity of the liver and the impaired absorption of nutrients are the main reasons that disrupt the metabolic balance in ESLD. Identifying patients that are approaching the state of malnutrition by simple and easily applied methods is necessary in order to provide nutritional support to those that need it most. According to the European Society for Clinical Nutrition and Metabolism, simple bedside methods such as Subjective Global Assessment and anthropometric parameters are reliable in assessing the nutritional state of cirrhotic patients. Correcting the nutrient deficit of the affected patients is mandatory. Avoidance of alcohol and excess fat and ingestion of 4-6 meals/day containing carbohydrates and protein are the most common recommendations. In severe malnutrition, initiation of enteral feeding and/or use of special formulae such as branched-chain amino acid-enriched nutrient mixtures are often recommended. Enteral nutrition improves nutritional status and liver function, reduces complications, prolongs survival and is therefore indicated.     

肝硬化患者常用的营养风险评价方法与比较

肝硬化患者常存在不同程度的营养不良,主要表现为蛋白质-能量营养不良。患者的营养状况能影响预后和生存率,但临床医生并未对此给予足够重视,且肝硬化患者的营养不良常被漏诊。回顾近年来几种常用营养评估方法在肝硬化患者中的相关研究,总结每种营养评估方法的特点,为临床医生进行营养评估提供参考。