Digestive Diseases and Sciences

, Volume 61, Issue 6, pp 1735–1743 | Cite as

The Royal Free Hospital-Nutritional Prioritizing Tool Is an Independent Predictor of Deterioration of Liver Function and Survival in Cirrhosis

  • Sarah Maria Borhofen
  • Carmen Gerner
  • Jennifer Lehmann
  • Rolf Fimmers
  • Jan Görtzen
  • Beate Hey
  • Franziska Geiser
  • Christian P. Strassburg
  • Jonel TrebickaEmail author
Original Article


Background and Aims

Malnutrition might affect survival and severity of complications in cirrhotic patients. However, adequate evaluation of the nutritional status is a difficult task since the common assessment tools are either inappropriate or too complicated. A simpler method could evaluate the patient’s risk for malnutrition instead of the nutritional status itself. This study evaluated the prediction of clinical deterioration and transplant-free survival in patients with chronic liver disease by two nutritional risk scores.


In 84 cirrhotic patients, Nutritional Risk Screening (NRS), Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT), and the chronic liver disease questionnaire have been assessed. These patients were evaluated at a second time point after a median observation time of 500 days. Another cohort of 64 patients was collected to validate the findings.


Of the included patients, 67.7 % were male with a median age of 57 years and a median Child score of 9. RFH-NPT classified 50.7 % of the patients as high-risk patients, and NRS assessed 44.6 % of the patients as moderate- to high-risk patients. RFH-NPT correlated with clinical deterioration, severity of disease (Child score, MELD score), and clinical complications such as ascites, hepatorenal syndrome, and episodes of hepatic encephalopathy. RFH-NPT was an independent predictor of clinical deterioration and transplant-free survival. Furthermore, improvement in RFH-NPT within 500 days was associated with improved survival.


Assessing the patients’ risk for malnutrition by RFH-NPT may be a useful predictor of disease progression and outcome for patients with chronic liver disease.


Cirrhosis Nutritional assessment CLDQ NRS RFH-NPT 



Body mass index


Confidence interval


Chronic liver disease questionnaire


Hepatocellular carcinoma


Hepatic encephalopathy


Hepatorenal syndrome


Health-related quality of life


Model for end-stage liver disease


Nonalcoholic steatohepatitis


Nutritional Risk Screening


Primary sclerosing cholangitis


Royal Free Hospital-Nutritional Prioritizing Tool


Royal Free Hospital-Global Assessment


Receiver operating characteristic


Spontaneous bacterial peritonitis


Standard deviation


Subjective global assessment



JT is supported by Deutsche Forschungsgemeinschaft (SFB TRR57), H. J. & W. Hector Stiftung (M60.2), Ernst-Bertha-Grimmke-Stiftung (6/15), and European Union’s Horizon 2020 research and innovation program (No. 668031).

Compliance with ethical standards

Conflict of interest


Supplementary material

10620_2015_4015_MOESM1_ESM.jpg (555 kb)
Supplementary Figure 1 Nutritional risk assessment according to RFH-NPT. After assessing acute alcoholic hepatitis and tube feeding (direct indicators for high risk for malnutrition), patients are divided into 2 groups according to presence of fluid overload before further evaluation. (Adapted from Amodio et al. “The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus”, Hepatology 2013;58:325-336) (JPEG 554 kb)
10620_2015_4015_MOESM2_ESM.jpg (508 kb)
Supplementary Figure 2 Nutritional risk assessment according to NRS. Impairment of the patients’ nutritional status and severity of the patients’ disease are assessed with up to 3 points each, an additional point is awarded for age above 70 years. (Adapted from Kondrup et al. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr 2003;22:321-336.) (JPEG 508 kb)
10620_2015_4015_MOESM3_ESM.jpg (197 kb)
Supplementary Figure 3 MELD and matching RFH-NPT show an excellently correlation with each other. MELD and matching RFH-NPT correlate excellently with each other in the first cohort at inclusion (A) and follow-up after 8 month (B) as well as in our validation cohort (C). Data was correlated with Spearman-correlation (JPEG 197 kb)
10620_2015_4015_MOESM4_ESM.jpg (180 kb)
Supplementary Figure 4 Association of RFH-NPT- and NRS-Score with decompensation of liver disease. Mann–Whitney-testing shows that a lower RFH-NPT-Score is associated with history of variceal bleeding (A). Patients with a history of spontaneous bacterial peritonitis have significantly higher RFH-NPT-scores (B). A higher NRS-Score shows a trend towards correlation with presence of HCC (C). Data is shown as median ± SD (JPEG 179 kb)


  1. 1.
    D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44:217–231.CrossRefPubMedGoogle Scholar
  2. 2.
    Ferreira LG, Anastacio LR, Lima AS, Correia MITD. Predictors of mortality in patients on the waiting list for liver transplantation. Nutr Hosp. 2013;28:914–919.PubMedGoogle Scholar
  3. 3.
    Propst A, Propst T, Zangerl G, Ofner D, Judmaier G, Vogel W. Prognosis and life expectancy in chronic liver disease. Dig Dis Sci. 1995;40:1805–1815.CrossRefPubMedGoogle Scholar
  4. 4.
    Castellanos FM, Santana PS, Garcia JE, et al. Influence of hyponutrition on occurrence of complications and mortality among cirrhosis patients. Nutr Hosp. 2008;23:68–74.Google Scholar
  5. 5.
    Mesejo A, Juan M, Serrano A. Liver cirrhosis and encephalopathy: clinical and metabolic consequences and nutritional support. Nutr Hosp. 2008;23:8–18.PubMedGoogle Scholar
  6. 6.
    Iwasa M, Iwata K, Hara N, et al. Nutrition therapy using a multidisciplinary team improves survival rates in patients with liver cirrhosis. Nutrition. 2013;29:1418–1421.CrossRefPubMedGoogle Scholar
  7. 7.
    Younossi ZM, Guyatt G, Kiwi M, Boparai N, King D. Development of a disease specific questionnaire to measure health related quality of life in patients with chronic liver disease. Gut. 1999;45:295–300.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Parkash O, Iqbal R, Jafri F, Azam I, Jafri W. Frequency of poor quality of life and predictors of health related quality of life in cirrhosis at a tertiary care hospital Pakistan. BMC Res Notes. 2012;5:446.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Amodio P, Bemeur C, Butterworth R, et al. The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. Hepatology. 2013;58:325–336.CrossRefPubMedGoogle Scholar
  10. 10.
    Vieira PM, De-Souza DA, Oliveira LC. Nutritional assessment in hepatic cirrhosis; clinical, anthropometric, biochemical and hematological parameters. Nutr Hosp. 2013;28:1615–1621.PubMedGoogle Scholar
  11. 11.
    Landa-Galvan HV, Milke-Garcia MP, Leon-Oviedo C, et al. Nutritional assessment of alcoholic liver cirrhotic patients treated in the liver Clinic of the Mexico’s General Hospital. Nutr Hosp. 2012;27:2006–2014.PubMedGoogle Scholar
  12. 12.
    Kondrup J, Rasmussen HH, Hamberg O, Stanga Z. Ad Hoc EWG. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr. 2003;22:321–336.CrossRefPubMedGoogle Scholar
  13. 13.
    Schneider SM, Hebuterne X. Use of nutritional scores to predict clinical outcomes in chronic diseases. Nutr Rev. 2000;58:31–38.CrossRefPubMedGoogle Scholar
  14. 14.
    Durand F, Buyse S, Francoz C, et al. Prognostic value of muscle atrophy in cirrhosis using psoas muscle thickness on computed tomography. J Hepatol. 2014;60:1151–1157.CrossRefPubMedGoogle Scholar
  15. 15.
    Hanai T, Shiraki M, Nishimura K, et al. Sarcopenia impairs prognosis of patients with liver cirrhosis. Nutrition. 2015;31:193–199.CrossRefPubMedGoogle Scholar
  16. 16.
    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.CrossRefPubMedGoogle Scholar
  17. 17.
    Shi S, Han J, Yan M, Wang K, Yu H, Meng Q. Nutritional risk assessment in patients with chronic liver disease. Zhonghua Gan Zang Bing Za Zhi. 2014;22:536–539.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Sarah Maria Borhofen
    • 1
  • Carmen Gerner
    • 2
  • Jennifer Lehmann
    • 1
  • Rolf Fimmers
    • 3
  • Jan Görtzen
    • 1
  • Beate Hey
    • 4
  • Franziska Geiser
    • 4
  • Christian P. Strassburg
    • 1
    • 2
  • Jonel Trebicka
    • 1
    Email author
  1. 1.Department of Internal Medicine IUniversity of BonnBonnGermany
  2. 2.Center for Integrated Oncology (CIO)University of BonnBonnGermany
  3. 3.Institute of Medical Biometry, Informatics and EpidemiologyUniversity of BonnBonnGermany
  4. 4.Institute of Psychosomatic Medicine and PsychotherapyUniversity of BonnBonnGermany

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