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

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Abstract

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.

Methods

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.

Results

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.

Conclusion

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.

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Abbreviations

BMI:

Body mass index

CI:

Confidence interval

CLDQ:

Chronic liver disease questionnaire

HCC:

Hepatocellular carcinoma

HE:

Hepatic encephalopathy

HRS:

Hepatorenal syndrome

HRQL:

Health-related quality of life

MELD:

Model for end-stage liver disease

NASH:

Nonalcoholic steatohepatitis

NRS:

Nutritional Risk Screening

PSC:

Primary sclerosing cholangitis

RFH-NPT:

Royal Free Hospital-Nutritional Prioritizing Tool

RFH-GA:

Royal Free Hospital-Global Assessment

ROC:

Receiver operating characteristic

SBP:

Spontaneous bacterial peritonitis

SD:

Standard deviation

SGA:

Subjective global assessment

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Acknowledgments

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).

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    Authors and Affiliations

    1. Department of Internal Medicine I, University of Bonn, Sigmund-Freud Str. 25, 53105, Bonn, Germany

      Sarah Maria Borhofen, Jennifer Lehmann, Jan Görtzen, Christian P. Strassburg & Jonel Trebicka

    2. Center for Integrated Oncology (CIO), University of Bonn, Bonn, Germany

      Carmen Gerner & Christian P. Strassburg

    3. Institute of Medical Biometry, Informatics and Epidemiology, University of Bonn, Bonn, Germany

      Rolf Fimmers

    4. Institute of Psychosomatic Medicine and Psychotherapy, University of Bonn, Bonn, Germany

      Beate Hey & Franziska Geiser

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    1. Sarah Maria Borhofen
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    Correspondence to Jonel Trebicka.

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    Additional information

    Sarah Maria Borhofen, Carmen Gerner, and Jennifer Lehmann have contributed equally to this work.

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    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)

    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)

    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)

    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)

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    Borhofen, S.M., Gerner, C., Lehmann, J. 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 61, 1735–1743 (2016). https://doi.org/10.1007/s10620-015-4015-z

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