Advertisement

Nutrition in cirrhosis: Dos and Don’ts

  • Manuela Merli
    Correspondence
    Corresponding author. Address: Department of Translational And Precision Medicine, Viale dell’Universita’ 37, 00185 Rome, Italy. Tel/Fax: +39-06-49972001.
    Affiliations
    Department of Translational and Precision Medicine
    Search for articles by this author
Published:September 02, 2020DOI:https://doi.org/10.1016/j.jhep.2020.07.019

      Keywords

      Background

      Nutritional status is often impaired in people with chronic liver disease. The degree of malnutrition increases with increasing hepatic decompensation and has a significant effect on morbidity and mortality, mainly in those patients with refractory ascites, multiple hospitalizations, cholestatic cirrhosis or chronic persistent alcohol abuse.
      European Association for the Study of the Liver
      Clinical practice guidelines on nutrition in chronic liver disease.
      Nevertheless, with the increasing prevalence of obesity, diabetes and metabolic syndrome some patients with cirrhosis may appear overweight or obese despite being malnourished, especially in the setting of non-alcoholic fatty liver disease (NAFLD).
      • Berzigotti A.
      • Garcia-Tsao G.
      • Bosch J.
      • Grace N.
      • Burroughs A.
      • Morillas R.
      • et al.
      Obesity is an independent risk factor for clinical decompensation in patients with cirrhosis.

      Causes

      Multiple factors contribute to malnutrition in chronic liver disease. Liver impairment results in reduced energy availability and a state of “accelerated fasting” where energy derives from catabolism of adipose and muscles tissues. Indeed, sarcopenia, a depletion in muscle mass and either low muscle strength or low physical performance, is recognized as the “core” of nutritional impairment in chronic liver disease.
      Low testosterone, increased endotoxin levels, chronic inflammation, chronic hyperammonaemia, increased myostatin expression and mitochondrial dysfunction have all been suggested as participating players in muscle depletion.
      • Dasarathy S.
      • Merli M.
      Sarcopenia from mechanism to diagnosis and treatment in liver disease.
      Hypomobility and physical inactivity may further contribute.
      • Tandon P.
      • Raman M.
      • Mourtzakis M.
      • Merli M.
      A practical approach to nutritional screening and assessment in cirrhosis.
      The poor dietary intake commonly seen in patients with decompensated cirrhosis exacerbates the nutritional deficit and is frequently neglected by healthcare providers.

      Consequence

      Malnutrition in liver cirrhosis is not simply an accompanying condition but further worsens the prognosis of the disease. Malnutrition and sarcopenia are associated with higher complication rates in cirrhotic patients. Moreover, they are associated with increased mortality in hospitalized cirrhotic patients and those waiting for liver transplantation.
      • Kim G.
      • Kang S.H.
      • Kim M.Y.
      • Baik S.K.
      Prognostic value of sarcopenia in patients with liver cirrhosis: a systematic review and meta-analysis.

      Screening and assessment for malnutrition in cirrhosis

      Physicians of patients with a diagnosis of chronic liver disease or decompensated cirrhosis should always include the patient’s nutritional status in their evaluation. The first step is a rapid nutritional screening to identify patients “at risk”. Patients at risk are those with low BMI (<18), advanced liver disease (Child-Pugh C) and positive RFH-Nutritional Prioritizing Tool.
      European Association for the Study of the Liver
      Clinical practice guidelines on nutrition in chronic liver disease.
      Patients at risk should undergo a more complete nutritional assessment including the evaluation of sarcopenia. Even obese patients may be sarcopenic (sarcopenic obesity) and therefore should be scrutinized as well. Inquiring about dietary intake and food-related attitude and beliefs is recommended.
      • Montano-Loza A.J.
      • Angulo P.
      • Meza-Junco J.
      • Prado C.M.
      • Sawyer M.B.
      • Beaumont C.
      • et al.
      Sarcopenic obesity and myosteatosis are associated with higher mortality in patients with cirrhosis.
      This can be further assessed through the help of a dietitian.

      Sarcopenia

      Muscle mass is best assessed by CT-based cross-sectional-imaging, as its results are an independent predictor of a patient’s morbidity and mortality.
      • Montano-Loza A.J.
      • Angulo P.
      • Meza-Junco J.
      • Prado C.M.
      • Sawyer M.B.
      • Beaumont C.
      • et al.
      Sarcopenic obesity and myosteatosis are associated with higher mortality in patients with cirrhosis.
      For this purpose, an abdominal CT taken for the clinical assessment is commonly available. Dual energy X ray absorptiometry scans expose patients to significantly less radiation and have been proposed for the assessment of sarcopenia through the appendicular skeletal muscle index. Bioelectrical impedance and muscle ultrasound still require further validation. A bedside mid-arm – muscle circumference measurement has also been utilized, although it is limited by intra-operator variability. Completion of the evaluation occurs through assessment of muscle function, by the handgrip test and other more comprehensive physical performance assessments (time up and go or 6 minute walk distance test). Similar tests are also utilized to score a patient’s frailty. Increasing frailty in patients with liver disease is associated with worse outcome.
      • Lai J.C.
      • Covinsky K.E.
      • Dodge J.L.
      • Boscardin W.J.
      • Segev D.L.
      • Roberts J.P.
      • et al.
      Development of a novel frailty index to predict mortality in patients with end-stage liver disease.

      How to treat

      Guidelines have underlined the best nutritional approach in patients with cirrhosis.
      European Association for the Study of the Liver
      Clinical practice guidelines on nutrition in chronic liver disease.
      ,
      • Plauth M.
      • Bernal W.
      • Dasarathy S.
      • Merli M.
      • Plank L.D.
      • Schütz T.
      • et al.
      ESPEN guideline on clinical nutrition in liver disease.
      Non-overweight patients should receive a daily intake of 30–35 kcal/kg body weight and daily protein intake of 1.2–1.5 g/kg body weight. An eating pattern including breakfast and a late evening snack is utilized to shorten periods of fasting.
      • Tsien C.D.
      • McCullough A.J.
      • Dasarathy S.
      Late evening snack: exploiting a period of anabolic opportunity in cirrhosis.
      Hospitalized patients are more at risk of a deficient dietary intake. When oral diet is insufficient oral nutritional supplements or enteral nutrition are suggested. Micronutrient malnutrition should also be evaluated and treated. Obese patients with cirrhosis should follow a moderate caloric restriction while maintaining an adequate or even increased protein intake. Recent studies are exploring the possible advantages of adequate protein intake and moderate exercise to improve sarcopenia and frailty.
      • Tandon P.
      • Ismond K.P.
      • Riess K.
      • Duarte-Rojo A.
      • Al-Judaibi B.
      • Dunn M.A.
      • et al.
      Exercise in cirrhosis: translating evidence and experience to practice.

      Financial support

      Università degli Studi di Roma Sapienza (reference number: Finanziamento Bando Ateneo 2018, DMTP AR 05.04.07).

      Conflict of interest

      The author declares no conflict of interest.
      Please refer to the accompanying ICMJE disclosure forms for further details.

      Acknowledgements

      The author thanks Shani Feldman, medical student, for editorial assistance and Dr Simone di Cola, resident in Gastroenterology for planning the Figure.

      Supplementary data

      References

        • European Association for the Study of the Liver
        Clinical practice guidelines on nutrition in chronic liver disease.
        J Hepatol. 2019; 70: 172-193
        • Berzigotti A.
        • Garcia-Tsao G.
        • Bosch J.
        • Grace N.
        • Burroughs A.
        • Morillas R.
        • et al.
        Obesity is an independent risk factor for clinical decompensation in patients with cirrhosis.
        Hepatology. 2011; 54: 555-561
        • Dasarathy S.
        • Merli M.
        Sarcopenia from mechanism to diagnosis and treatment in liver disease.
        J Hepatol. 2016; 65: 1232-1244
        • Tandon P.
        • Raman M.
        • Mourtzakis M.
        • Merli M.
        A practical approach to nutritional screening and assessment in cirrhosis.
        Hepatology. 2017; 65: 1044-1057
        • Kim G.
        • Kang S.H.
        • Kim M.Y.
        • Baik S.K.
        Prognostic value of sarcopenia in patients with liver cirrhosis: a systematic review and meta-analysis.
        PLoS One. 2017; 12: e0186990
        • Montano-Loza A.J.
        • Angulo P.
        • Meza-Junco J.
        • Prado C.M.
        • Sawyer M.B.
        • Beaumont C.
        • et al.
        Sarcopenic obesity and myosteatosis are associated with higher mortality in patients with cirrhosis.
        J Cachexia Sarcopenia Muscle. 2016; 7: 126-135
        • Lai J.C.
        • Covinsky K.E.
        • Dodge J.L.
        • Boscardin W.J.
        • Segev D.L.
        • Roberts J.P.
        • et al.
        Development of a novel frailty index to predict mortality in patients with end-stage liver disease.
        Hepatology. 2017; 66: 564-574
        • Plauth M.
        • Bernal W.
        • Dasarathy S.
        • Merli M.
        • Plank L.D.
        • Schütz T.
        • et al.
        ESPEN guideline on clinical nutrition in liver disease.
        Clin Nutr. 2019; 38: 485-521
        • Tsien C.D.
        • McCullough A.J.
        • Dasarathy S.
        Late evening snack: exploiting a period of anabolic opportunity in cirrhosis.
        J Gastroenterol Hepatol. 2012; 27: 430-441
        • Tandon P.
        • Ismond K.P.
        • Riess K.
        • Duarte-Rojo A.
        • Al-Judaibi B.
        • Dunn M.A.
        • et al.
        Exercise in cirrhosis: translating evidence and experience to practice.
        J Hepatol. 2018; 69: 1164-1177