Nutritional assessment in patients with liver cirrhosis

Sara Haj Ali, Awni Abu Sneineh, Reem Hasweh, Sara Haj Ali, Awni Abu Sneineh, Reem Hasweh

Abstract

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.

Keywords: Cirrhosis; Frailty; Malnutrition; Nutrition; Nutritional assessment; Sarcopenia.

Conflict of interest statement

Conflict-of-interest statement: All authors report no relevant conflict of interest for this article.

©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.

Figures

Figure 1
Figure 1
Factors contributing to malnutrition and sarcopenia in liver cirrhosis.
Figure 2
Figure 2
Algorithm for nutritional screening and assessment in liver cirrhosis. Adapted from the European Association for the Study of the Liver (EASL) clinical practice guidelines (with permission from Elsevier). Citation: European Association for the Study of the Liver. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J. Hepatol. 2019, 70, 172-193. Copyright© 2018 European Association for the Study of the Liver. Published by Elsevier. BMI: Body mass index (Supplementary material).

References

    1. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol. 2019;70:172–193.
    1. Traub J, Reiss L, Aliwa B, Stadlbauer V. Malnutrition in Patients with Liver Cirrhosis. Nutrients. 2021;13
    1. Naqvi IH, Mahmood K, Salekeen S, Akhter ST. Determining the frequency and severity of malnutrition and correlating it with the severity of liver cirrhosis. Turk J Gastroenterol. 2013;24:415–422.
    1. Nutritional status in cirrhosis. Italian Multicentre Cooperative Project on Nutrition in Liver Cirrhosis. J Hepatol. 1994;21:317–325.
    1. Bruch JP, Álvares-DA-Silva MR, Alves BC, Dall'alba V. Reduced hand grip strength in overweight and obese chronic hepatitis c patients. Arq Gastroenterol. 2016;53:31–35.
    1. Normatov I, Kaplan S, Azzam RK. Nutrition in Pediatric Chronic Liver Disease. Pediatr Ann. 2018;47:e445–e451.
    1. Kalaitzakis E, Bosaeus I, Ohman L, Björnsson E. Altered postprandial glucose, insulin, leptin, and ghrelin in liver cirrhosis: correlations with energy intake and resting energy expenditure. Am J Clin Nutr. 2007;85:808–815.
    1. Plauth M, Schütz ET. Cachexia in liver cirrhosis. Int J Cardiol. 2002;85:83–87.
    1. Gunnarsdottir SA, Sadik R, Shev S, Simrén M, Sjövall H, Stotzer PO, Abrahamsson H, Olsson R, Björnsson ES. Small intestinal motility disturbances and bacterial overgrowth in patients with liver cirrhosis and portal hypertension. Am J Gastroenterol. 2003;98:1362–1370.
    1. Owen OE, Reichle FA, Mozzoli MA, Kreulen T, Patel MS, Elfenbein IB, Golsorkhi M, Chang KH, Rao NS, Sue HS, Boden G. Hepatic, gut, and renal substrate flux rates in patients with hepatic cirrhosis. J Clin Invest. 1981;68:240–252.
    1. Ooi PH, Gilmour SM, Yap J, Mager DR. Effects of branched chain amino acid supplementation on patient care outcomes in adults and children with liver cirrhosis: A systematic review. Clin Nutr ESPEN. 2018;28:41–51.
    1. Dasarathy S, Merli M. Sarcopenia from mechanism to diagnosis and treatment in liver disease. J Hepatol. 2016;65:1232–1244.
    1. Grossmann M, Hoermann R, Gani L, Chan I, Cheung A, Gow PJ, Li A, Zajac JD, Angus P. Low testosterone levels as an independent predictor of mortality in men with chronic liver disease. Clin Endocrinol (Oxf) 2012;77:323–328.
    1. Zhao VM, Ziegler TR. Nutrition support in end-stage liver disease. Crit Care Nurs Clin North Am. 2010;22:369–380.
    1. Peng S, Plank LD, McCall JL, Gillanders LK, McIlroy K, Gane EJ. Body composition, muscle function, and energy expenditure in patients with liver cirrhosis: a comprehensive study. Am J Clin Nutr. 2007;85:1257–1266.
    1. Li D, Li Y, Dai W, Wang H, Qiu C, Feng S, Zhou Q, Wang W, Feng X, Yao K, Liu Y, Yang Y, Yang Z, Xu X, Li S, Wei J, Zhou K. Intestinal Bacteroides sp. Imbalance Associated With the Occurrence of Childhood Undernutrition in China. Front Microbiol. 2019;10:2635.
    1. Dinh DM, Ramadass B, Kattula D, Sarkar R, Braunstein P, Tai A, Wanke CA, Hassoun S, Kane AV, Naumova EN, Kang G, Ward HD. Longitudinal Analysis of the Intestinal Microbiota in Persistently Stunted Young Children in South India. PLoS One. 2016;11:e0155405.
    1. Wallace JM. Comment on "The ultrastructure of type I collagen at nanoscale: large or small D-spacing distribution? Nanoscale. 2015;7:1233–1234.
    1. Stadlbauer V, Komarova I, Klymiuk I, Durdevic M, Reisinger A, Blesl A, Rainer F, Horvath A. Disease severity and proton pump inhibitor use impact strongest on faecal microbiome composition in liver cirrhosis. Liver Int. 2020;40:866–877.
    1. Horvath A, Rainer F, Bashir M, Leber B, Schmerboeck B, Klymiuk I, Groselj-Strele A, Durdevic M, Freedberg DE, Abrams JA, Fickert P, Stiegler P, Stadlbauer V. Biomarkers for oralization during long-term proton pump inhibitor therapy predict survival in cirrhosis. Sci Rep. 2019;9:12000.
    1. Zenith L, Meena N, Ramadi A, Yavari M, Harvey A, Carbonneau M, Ma M, Abraldes JG, Paterson I, Haykowsky MJ, Tandon P. Eight weeks of exercise training increases aerobic capacity and muscle mass and reduces fatigue in patients with cirrhosis. Clin Gastroenterol Hepatol. 2014;12:1920–6.e2.
    1. Li TH, Liu CW, Huang CC, Tsai YL, Huang SF, Yang YY, Tsai CY, Hou MC, Lin HC. Non-Selective Beta-Blockers Decrease Infection, Acute Kidney Injury Episodes, and Ameliorate Sarcopenic Changes in Patients with Cirrhosis: A Propensity-Score Matching Tertiary-Center Cohort Study. J Clin Med. 2021;10
    1. Lattanzi B, Gioia S, Di Cola S, D'Ambrosio D, Nardelli S, Tavano D, Farcomeni A, Merli M, Riggio O. Prevalence and impact of sarcopenia in non-cirrhotic portal hypertension. Liver Int. 2019;39:1937–1942.
    1. Plauth M, Schütz T, Buckendahl DP, Kreymann G, Pirlich M, Grüngreiff S, Romaniuk P, Ertl S, Weiss ML, Lochs H. Weight gain after transjugular intrahepatic portosystemic shunt is associated with improvement in body composition in malnourished patients with cirrhosis and hypermetabolism. J Hepatol. 2004;40:228–233.
    1. Allard JP, Chau J, Sandokji K, Blendis LM, Wong F. Effects of ascites resolution after successful TIPS on nutrition in cirrhotic patients with refractory ascites. Am J Gastroenterol. 2001;96:2442–2447.
    1. Arora S, Mattina C, McAnenny C, O’Sullivan N, McGeeney L, Calder N, Gatiss G, Davidson B, Morgan M. 608 The development and validation of a nutritional prioritising tool for use in patients with chronic liver disease. J Hepatol 2012;56 Suppl 2, S241.
    1. Borhofen SM, Gerner C, Lehmann J, Fimmers R, Görtzen J, Hey B, Geiser F, Strassburg CP, Trebicka J. The Royal Free Hospital-Nutritional Prioritizing Tool Is an Independent Predictor of Deterioration of Liver Function and Survival in Cirrhosis. Dig Dis Sci. 2016;61:1735–1743.
    1. 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.
    1. White JV, Guenter P, Jensen G, Malone A, Schofield M Academy Malnutrition Work Group; A. S.P.E.N. Malnutrition Task Force; A.S.P.E.N. Board of Directors. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition) JPEN J Parenter Enteral Nutr. 2012;36:275–283.
    1. Ahluwalia N, Dwyer J, Terry A, Moshfegh A, Johnson C. Update on NHANES Dietary Data: Focus on Collection, Release, Analytical Considerations, and Uses to Inform Public Policy. Adv Nutr. 2016;7:121–134.
    1. Tandon P, Raman M, Mourtzakis M, Merli M. A practical approach to nutritional screening and assessment in cirrhosis. Hepatology. 2017;65:1044–1057.
    1. De Keyzer W, Huybrechts I, De Vriendt V, Vandevijvere S, Slimani N, Van Oyen H, De Henauw S. Repeated 24-hour recalls versus dietary records for estimating nutrient intakes in a national food consumption survey. Food Nutr Res. 2011;55
    1. Tandon P, Ney M, Irwin I, Ma MM, Gramlich L, Bain VG, Esfandiari N, Baracos V, Montano-Loza AJ, Myers RP. Severe muscle depletion in patients on the liver transplant wait list: its prevalence and independent prognostic value. Liver Transpl. 2012;18:1209–1216.
    1. Tandon P, Low G, Mourtzakis M, Zenith L, Myers RP, Abraldes JG, Shaheen AA, Qamar H, Mansoor N, Carbonneau M, Ismond K, Mann S, Alaboudy A, Ma M. A Model to Identify Sarcopenia in Patients With Cirrhosis. Clin Gastroenterol Hepatol. 2016;14:1473–1480.e3.
    1. Keller U. Nutritional Laboratory Markers in Malnutrition. J Clin Med. 2019;8
    1. Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, Jeejeebhoy KN. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11:8–13.
    1. Hasse J, Strong S, Gorman MA, Liepa G. Subjective global assessment: alternative nutrition-assessment technique for liver-transplant candidates. Nutrition. 1993;9:339–343.
    1. Ferreira LG, Anastácio LR, Lima AS, Correia MI. Assessment of nutritional status of patients waiting for liver transplantation. Clin Transplant. 2011;25:248–254.
    1. Morgan MY, Madden AM, Soulsby CT, Morris RW. Derivation and validation of a new global method for assessing nutritional status in patients with cirrhosis. Hepatology. 2006;44:823–835.
    1. Sasidharan M, Nistala S, Narendhran RT, Murugesh M, Bhatia SJ, Rathi PM. Nutritional status and prognosis in cirrhotic patients. Trop Gastroenterol. 2012;33:257–264.
    1. Kalafateli M, Mantzoukis K, Choi Yau Y, Mohammad AO, Arora S, Rodrigues S, de Vos M, Papadimitriou K, Thorburn D, O'Beirne J, Patch D, Pinzani M, Morgan MY, Agarwal B, Yu D, Burroughs AK, Tsochatzis EA. Malnutrition and sarcopenia predict post-liver transplantation outcomes independently of the Model for End-stage Liver Disease score. J Cachexia Sarcopenia Muscle. 2017;8:113–121.
    1. Lai JC, Rahimi RS, Verna EC, Kappus MR, Dunn MA, McAdams-DeMarco M, Haugen CE, Volk ML, Duarte-Rojo A, Ganger DR, O'Leary JG, Dodge JL, Ladner D, Segev DL. Frailty Associated With Waitlist Mortality Independent of Ascites and Hepatic Encephalopathy in a Multicenter Study. Gastroenterology. 2019;156:1675–1682.
    1. Lai JC, Feng S, Terrault NA, Lizaola B, Hayssen H, Covinsky K. Frailty predicts waitlist mortality in liver transplant candidates. Am J Transplant. 2014;14:1870–1879.
    1. Alberino F, Gatta A, Amodio P, Merkel C, Di Pascoli L, Boffo G, Caregaro L. Nutrition and survival in patients with liver cirrhosis. Nutrition. 2001;17:445–450.
    1. Morgan MY, Madden AM, Jennings G, Elia M, Fuller NJ. Two-component models are of limited value for the assessment of body composition in patients with cirrhosis. Am J Clin Nutr. 2006;84:1151–1162.
    1. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, Martin FC, Michel JP, Rolland Y, Schneider SM, Topinková E, Vandewoude M, Zamboni M European Working Group on Sarcopenia in Older People. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010;39:412–423.
    1. Chen LK, Liu LK, Woo J, Assantachai P, Auyeung TW, Bahyah KS, Chou MY, Chen LY, Hsu PS, Krairit O, Lee JS, Lee WJ, Lee Y, Liang CK, Limpawattana P, Lin CS, Peng LN, Satake S, Suzuki T, Won CW, Wu CH, Wu SN, Zhang T, Zeng P, Akishita M, Arai H. Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc. 2014;15:95–101.
    1. van Vugt JL, Levolger S, de Bruin RW, van Rosmalen J, Metselaar HJ, IJzermans JN. Systematic Review and Meta-Analysis of the Impact of Computed Tomography-Assessed Skeletal Muscle Mass on Outcome in Patients Awaiting or Undergoing Liver Transplantation. Am J Transplant. 2016;16:2277–2292.
    1. Campbell IT, Watt T, Withers D, England R, Sukumar S, Keegan MA, Faragher B, Martin DF. Muscle thickness, measured with ultrasound, may be an indicator of lean tissue wasting in multiple organ failure in the presence of edema. Am J Clin Nutr. 1995;62:533–539.
    1. Woodward AJ, Wallen MP, Ryan J, Ward LC, Coombes JS, Macdonald GA. Evaluation of techniques used to assess skeletal muscle quantity in patients with cirrhosis. Clin Nutr ESPEN. 2021;44:287–296.
    1. Strauss BJ, Gibson PR, Stroud DB, Borovnicar DJ, Xiong DW, Keogh J. Total body dual X-ray absorptiometry is a good measure of both fat mass and fat-free mass in liver cirrhosis compared to "gold-standard" techniques. Melbourne Liver Group. Ann N Y Acad Sci. 2000;904:55–62.
    1. Belarmino G, Gonzalez MC, Sala P, Torrinhas RS, Andraus W, D'Albuquerque LAC, Pereira RMR, Caparbo VF, Ferrioli E, Pfrimer K, Damiani L, Heymsfield SB, Waitzberg DL. Diagnosing Sarcopenia in Male Patients With Cirrhosis by Dual-Energy X-Ray Absorptiometry Estimates of Appendicular Skeletal Muscle Mass. JPEN J Parenter Enteral Nutr. 2018;42:24–36.
    1. Eriksen CS, Kimer N, Suetta C, Møller S. Arm lean mass determined by dual-energy X-ray absorptiometry is superior to characterize skeletal muscle and predict sarcopenia-related mortality in cirrhosis. Am J Physiol Gastrointest Liver Physiol. 2021;320:G729–G740.
    1. Sinclair M, Hoermann R, Peterson A, Testro A, Angus PW, Hey P, Chapman B, Gow PJ. Use of Dual X-ray Absorptiometry in men with advanced cirrhosis to predict sarcopenia-associated mortality risk. Liver Int. 2019;39:1089–1097.
    1. Bunchorntavakul C, Supanun R, Atsawarungruangkit A. Nutritional Status and its Impact on Clinical Outcomes for Patients Admitted to Hospital with Cirrhosis. J Med Assoc Thai. 2016;99 Suppl 2:S47–S55.
    1. Maharshi S, Sharma BC, Srivastava S. Malnutrition in cirrhosis increases morbidity and mortality. J Gastroenterol Hepatol. 2015;30:1507–1513.
    1. Huisman EJ, Trip EJ, Siersema PD, van Hoek B, van Erpecum KJ. Protein energy malnutrition predicts complications in liver cirrhosis. Eur J Gastroenterol Hepatol. 2011;23:982–989.
    1. Lindqvist C, Majeed A, Wahlin S. Body composition assessed by dual-energy X-ray absorptiometry predicts early infectious complications after liver transplantation. J Hum Nutr Diet. 2017;30:284–291.
    1. Ruiz-Margáin A, Macías-Rodríguez RU, Ampuero J, Cubero FJ, Chi-Cervera L, Ríos-Torres SL, Duarte-Rojo A, Espinosa-Cuevas Á, Romero-Gómez M, Torre A. Low phase angle is associated with the development of hepatic encephalopathy in patients with cirrhosis. World J Gastroenterol. 2016;22:10064–10070.
    1. Gunsar F, Raimondo ML, Jones S, Terreni N, Wong C, Patch D, Sabin C, Burroughs AK. Nutritional status and prognosis in cirrhotic patients. Aliment Pharmacol Ther. 2006;24:563–572.
    1. Montano-Loza AJ, Meza-Junco J, Prado CM, Lieffers JR, Baracos VE, Bain VG, Sawyer MB. Muscle wasting is associated with mortality in patients with cirrhosis. Clin Gastroenterol Hepatol. 2012;10:166–173, 173.e1.
    1. Englesbe MJ, Patel SP, He K, Lynch RJ, Schaubel DE, Harbaugh C, Holcombe SA, Wang SC, Segev DL, Sonnenday CJ. Sarcopenia and mortality after liver transplantation. J Am Coll Surg. 2010;211:271–278.
    1. Montano-Loza AJ, Angulo P, Meza-Junco J, Prado CM, Sawyer MB, Beaumont C, Esfandiari N, Ma M, Baracos VE. Sarcopenic obesity and myosteatosis are associated with higher mortality in patients with cirrhosis. J Cachexia Sarcopenia Muscle. 2016;7:126–135.
    1. Tandon P, Montano-Loza AJ, Lai JC, Dasarathy S, Merli M. Sarcopenia and frailty in decompensated cirrhosis. J Hepatol. 2021;75 Suppl 1:S147–S162.

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