Nutritional Assessment and Management for Hospitalized Patients with Cirrhosis
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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.
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.
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.
KeywordsMalnutrition Sarcopenia Cirrhosis BCAA Nutrition Physical activity
Compliance with Ethical Standards
Conflict of Interest
Barbara Lattanzi, Daria D’Ambrosio, and Veronica Fedele declare no conflicts of interest. Manuela Merli reports personal fees from Kedrion and grants from Griffols, outside the submitted work.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Amodio P, Bemeur C, Butterworth R, Cordoba J, Kato A, Montagnese S, et al. The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. Hepatology. 2013;58(1):325–36. https://doi.org/10.1002/hep.26370.CrossRefPubMedGoogle Scholar
- 6.Muscaritoli M, Anker SD, Argilés J, Aversa Z, Bauer JM, Biolo G, et al. Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) ‘cachexia-anorexia in chronic wasting diseases’ and ‘nutrition in geriatrics’. Clin Nutr. 2010;29:154–9. https://doi.org/10.1016/j.clnu.2009.12.004.CrossRefPubMedGoogle Scholar
- 9.• Montano-Loza AJ, Angulo P, Meza-Junco J, Prado CM, Sawyer MB, Beaumont C, et al. Sarcopenic obesity and myosteatosis are associated with higher mortality in patients with cirrhosis. J Cachexia Sarcopenia Muscle. 2016;7(2):126–35. https://doi.org/10.1002/jcsm.12039. A study that clarifies that sarcopenic obesity is very common in cirrhotic patients and is associated with higher mortality in cirrhosis.CrossRefPubMedGoogle Scholar
- 12.•• Tandon R, Mourtzakis M, Merli M. A Practical Approach to Nutritional Screening and Assessment in Cirrhosis. Hepatology. 2017;65(3):1044–57. https://doi.org/10.1002/hep.29003. A study that identifies the relevance of malnutrition in patients with liver cirrhosis, and suggests methods of screening and assessment.CrossRefPubMedGoogle Scholar
- 14.Borhofen SM, Gerner C, Lehmann J, Fimmers R, Görtzen J, Hey B, et al. 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(6):1735–43. https://doi.org/10.1007/s10620-015-4015-z.CrossRefPubMedGoogle Scholar
- 15.White JV, Guenter P, Jensen G, Malone A, Schofield M, Acad-emy Malnutrition Work Group, et al. Consensus statement: Acade-my of Nutrition and Dietetics and American Society for Paren-teral and Enteral Nutrition: characteristics recommended for thei dentification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36:275–83. https://doi.org/10.1177/0148607112440285.CrossRefPubMedGoogle Scholar
- 16.Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010;39:412–23. https://doi.org/10.1093/ageing/afq034.CrossRefPubMedPubMedCentralGoogle Scholar
- 17.•• Dasarathy S, Merli M. Sarcopenia from mechanism to diagnosis and treatment in liver disease. J Hepatol. 2016;65:1232–44. https://doi.org/10.1016/j.jhep.2016.07.040. An extensive review that clarifies the main pathogenic mechanisms of sarcopenia and explains how to diagnose it and possible treatment approaches.CrossRefPubMedPubMedCentralGoogle Scholar
- 21.•• Carey EJ, Lai JC, Wang CW, Dasarathy S, Lobach I, Montano-Loza AJ, et al. Fitness, Life Enhancement, and Exercise in Liver Transplantation Consortium. A multicenter study to define sarcopenia in patients with end-stage liver disease. Liver Transpl. 2017;23(5):625–33. https://doi.org/10.1002/lt.24750. A multicenter study that identifies the cutoff for the diagnosis of CT assessed sarcopenia in cirrhotic patients predicting mortality at 6 months.CrossRefPubMedGoogle Scholar
- 28.Cruz RJ Jr, Dew MA, Myaskovsky L, Goodpaster B, Fox K, Fontes P, et al. Objective radiologic assessment of body composition in patients with endstage liver disease: going beyond the BMI. Transplantation. 2013;95:617–22. https://doi.org/10.1097/TP.0b013e31827a0f27.CrossRefPubMedPubMedCentralGoogle Scholar
- 31.Kalafateli M, Mantzoukis K, Choi Yau Y, Mohammad AO, Arora S, Rodrigues S, et al. Malnutrition and sarcopenia predict post-liver transplantation outcomes independently of the Model for End-stage Liver Disease score. J Cachexia Sarcopenia Muscle. 2017;8(1):113–21. https://doi.org/10.1002/jcsm.12095.CrossRefPubMedGoogle Scholar
- 32.Figueiredo FA, Dickson ER, Pasha TM, Porayko MK, Therneau TM, Malinchoc M, et al. Utility of standard nutritional parameters in detecting body cell mass depletion in patients with end-stage liver dis-ease. Liver Transpl. 2000;6:575–81. https://doi.org/10.1053/jlts.2000.9736.CrossRefPubMedGoogle Scholar
- 33.Giusto M, Lattanzi B, Albanese C, Galtieri A, Farcomeni A, Giannelli V, et al. Sarcopenia in liver cirrhosis: the role of computed tomography scan for the assessment of muscle mass compared with dual-energy X-ray absorptiometry and anthropometry. Eur J Gastroenterol Hepatol. 2015;27(3):328–34. https://doi.org/10.1097/MEG.0000000000000274.CrossRefPubMedGoogle Scholar
- 34.Belarmino G, Gonzalez MC, Torrinhas RS, Sala P, Andraus W, D'Albuquerque LA, et al. Phase angle obtained by bioelectrical impedance analysis independently predicts mortality in patients with cirrhosis. World J Hepatol. 2017;9(7):401–8. https://doi.org/10.4254/wjh.v9.i7.401.CrossRefPubMedPubMedCentralGoogle Scholar
- 37.Alvares-da-Silva MR. Reverbel da Silveira T. Comparison between handgrip strength, subjective global assessment, and prognostic nutritional index in assessing malnutrition and predicting clinical outcome in cirrhotic outpatients. Nutrition. 2005;21:113–7. https://doi.org/10.1016/j.nut.2004.02.002.CrossRefPubMedGoogle Scholar
- 40.McClave SA, DiBaise JK, Mullin GE, Martindale RG. ACG Clinical Guideline: Nutrition therapy in the adult hospitalized patient. Am J Gastroenterol. 2016; https://doi.org/10.1038/ajg.2016.28.
- 41.Hiraoka A, Michitaka K, Kiguchi D, Izumoto H, Ueki H, Kaneto M, et al. Efficacy of branched-chain amino acid supplementation and walking exercise for preventing sarcopenia in patients with liver cirrhosis. Eur J Gastroenterol Hepatol. 2017;29(12):1416–23. https://doi.org/10.1097/MEG.0000000000000986.CrossRefPubMedGoogle Scholar
- 42.Koya S, Kawaguchi T, Hashida R, Goto E, Matsuse H, Saito H, et al. Effects of in-hospital exercise on liver function, physical ability and muscle mass during treatment of hepatoma in patients with chronic liver disease. Hepatol Res. 2016;47:E22–34. https://doi.org/10.1111/hepr.12718.CrossRefPubMedGoogle Scholar
- 44.Román E, García-Galcerán C, Torrades T, Herrera S, Marín A, Donate M, et al. Effects of an exercise programme on functional capacity. Body composition and risk of falls in patients with cirrhosis: a randomized clinicaltrial. PLoS One. 2016;11:e0151652. https://doi.org/10.1371/journal.pone.0151652.CrossRefPubMedPubMedCentralGoogle Scholar
- 46.Zenith L, Meena N, Ramadi A, Yavari M, Harvey A, Carbonneau M, et al. 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. https://doi.org/10.1016/j.cgh.2014.04.016.CrossRefPubMedGoogle Scholar
- 57.Les I, Doval E, García-Martínez R, Planas M, Cárdenas G, Gómez P, et al. Effects of branched-chain amino acids supplementation in patients with cirrhosis and a previous episode of hepatic encephalopathy: a randomized study. Am J Gastroenterol. 2011;106(6):1081–8. https://doi.org/10.1038/ajg.2011.9.CrossRefPubMedGoogle Scholar
- 59.• Tsien C, Davuluri G, Singh D, Allawy A, Ten Have GA, Thapaliya S, et al. Metabolic and molecular responses to leucine-enriched branched chain amino acid supplementation in the skeletal muscle of alcoholic cirrhosis. Hepatology. 2015;61(6):2018–29. https://doi.org/10.1002/hep.27717. A study showing that leucine-enriched branched chain amino acid supplementation improves sarcopenia and the mechanisms by which it exerts this action in patients with alcoholic cirrhosis.CrossRefPubMedPubMedCentralGoogle Scholar