Highlights
- •Malnutrition has a significant negative effect on outcome in patients with cirrhosis.
- •Accurate information on daily energy requirements is essential for effective nutritional management.
- •Prediction equations provide estimates of daily energy expenditure, but these vary significantly by ethnicity.
- •Where available, resting energy expenditure should be measured using indirect calorimetry.
Background & Aims
Malnutrition is associated with adverse clinical outcomes in patients with cirrhosis.
Accurate assessment of energy requirements is needed to optimize dietary intake. Resting
energy expenditure (REE), the major component of total energy expenditure, can be
measured using indirect calorimetry (mREE) or estimated using prediction equations
(pREE). This study assessed the usefulness of predicted estimates of REE in this patient
population.
Methods
Individual mREE data were available for 900 patients with cirrhosis (mean [±1 SD]
age 55.7±11.6 years-old; 70% men; 52% south-east Asian) and 282 healthy controls (mean
age 36.0±12.8 years-old; 52% men; 18% south-east Asian). Metabolic status was classified
using thresholds based on the mean ± 1 SD of the mREE in the healthy controls. Comparisons
were made between mREE and pREE estimates obtained using the Harris-Benedict, Mifflin,
Schofield and Henry equations. Stepwise regression was used to build 3 new prediction
models which included sex, ethnicity, body composition measures, and model for end-stage
liver disease scores.
Results
The mean mREE was significantly higher in patients than controls when referenced to
dry body weight (22.4±3.8 cf. 20.8±2.6 kcal/kg/24 hr; p <0.001); there were no significant sex differences. The mean mREE was significantly
higher in Caucasian than Asian patients (23.1±4.4 cf. 21.7±2.9 kcal/kg/24 hr; p <0.001). Overall, 37.1% of Caucasian and 25.3% of Asian patients were classified as
hypermetabolic. The differences between mREE and pREE were both statistically and
clinically relevant; in the total patient population, pREE estimates ranged from 501
kcal/24 hr less to 548 kcal/24 hr more than the mREE. Newly derived prediction equations
provided better estimates of mREE but still had limited clinical utility.
Conclusions
Prediction equations do not provide useful estimates of REE in patients with cirrhosis.
REE should be directly measured.
Lay summary
People with cirrhosis are often malnourished and this has a detrimental effect on
outcome. Provision of an adequate diet is very important and is best achieved by measuring
daily energy requirements and adjusting dietary intake accordingly. Prediction equations,
which use information on age, sex, weight, and height can be used to estimate energy
requirements; however, the results they provide are not accurate enough for clinical
use, particularly as they vary according to sex and ethnicity.
Graphical abstract
Graphical Abstract
Keywords
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References
- Protein-calorie malnutrition in liver cirrhosis.Clin Investig. 1992; 70: 478-486
- Nutritional status in cirrhosis.J Hepatol. 1994; 21: 317-325
- Nutritional status and survival of patients with liver cirrhosis: anthropometric evaluation.Minerva Gastroenterol Dietol. 1996; 42: 57-60
- Malnutrition in cirrhosis increases morbidity and mortality.J Gastroenterol Hepatol. 2015; 30: 1507-1513
- Determining whether low protein intake (<1.0 g/kg) is a risk factor for malnutrition in patients with cirrhosis.J Clin Med. 2021; 10: 2164
- Influence of selected patient variables and operative blood loss on six-month survival following liver transplantation.Semin Liver Dis. 1985; 5: 385-393
- Degree of preoperative malnutrition is predictive of postoperative morbidity and mortality in liver transplant recipients.Transplantation. 1994; 57: 469-472
- Relationship of protein calorie malnutrition to alcoholic liver disease: a reexamination of data from two Veterans Administration Cooperative Studies.Alcohol Clin Exp Res. 1995; 19: 635-641
- Does malnutrition affect survival in cirrhosis? PINC (Policentrica Italiana Nutrizione Cirrosi).Hepatology. 1996; 23: 1041-1046
- Protein energy malnutrition predicts complications in liver cirrhosis.Eur J Gastroenterol Hepatol. 2011; 23: 982-989
- 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
- Systematic review with meta-analysis: screening and assessment tools in cirrhosis.Liver Int. 2020; 40: 664-673
- VA Cooperative Study on Alcoholic Hepatitis. III: changes in protein-calorie malnutrition associated with 30 days of hospitalization with and without enteral nutritional therapy.JPEN J Parenter Enteral Nutr. 1985; 9: 590-596
- Effect of total enteral nutrition on the short-term outcome of severely malnourished cirrhotics. A randomized controlled trial.Gastroenterology. 1990; 98: 715-720
- Accelerated improvement of alcoholic liver disease with enteral nutrition.Gastroenterology. 1992; 102: 200-205
- Controlled trial on nutrition supplementation in outpatients with symptomatic alcoholic cirrhosis.JPEN J Parenter Enteral Nutr. 1993; 17: 119-124
- A study of oral nutritional support with oxandrolone in malnourished patients with alcoholic hepatitis: results of a Department of Veterans Affairs cooperative study.Hepatology. 1993; 17: 564-576
- Short-term changes in energy metabolism after 1 month of a regular oral diet in severely malnourished cirrhotic patients.Metabolism. 1995; 44: 765-770
- A comprehensive nutrition-focused quality improvement programme reduces 30-day readmissions and length of stay in hospitalized patients.JPEN J Parenter Enteral Nutr. 2017; 41: 384-391
- ESPEN guidelines for nutrition in liver disease and transplantation.Clin Nutr. 1997; 16: 43-55
- ESPEN Guidelines on enteral nutrition: liver disease.Clin Nutr. 2006; 25: 285-294
- ESPEN guideline on clinical nutrition in liver disease.Clin Nutr. 2019; 38: 485-521
- The nutritional management of hepatic encephalopathy in patients with cirrhosis: international society for hepatic encephalopathy and nitrogen metabolism consensus.Hepatology. 2013; 58: 325-336
- EASL Clinical Practice Guidelines on nutrition in chronic liver disease.J Hepatol. 2019; 70: 172-193
- Malnutrition, frailty, and sarcopenia in patients with cirrhosis:2021 practice guidance by the American association for the study of liver diseases.Hepatology. 2021; 74: 1611-1644
- Resting energy expenditure in patients with end stage liver disease and normal population.JPEN. 1987; 11: 305-308
- Energy metabolism in patients with acute and chronic liver disease.Hepatology. 1990; 11: 387-393
- Energy expenditure and substrate oxidation in patients with cirrhosis: the impact of cause, clinical staging and nutritional state.Hepatology. 1992; 15: 782-794
- Hypermetabolism in clinically stable patients with liver cirrhosis.Am J Clin Nutr. 1999; 69: 1194-1201
- Resting energy expenditure should be measured in patients with cirrhosis, not predicted.Hepatology. 1999; 30: 655-664
- Metabolic, endocrine, haemodynamic and pulmonary responses to different types of exercise in individuals with normal or reduced liver function.Eur J Appl Physiol Occup Physiol. 1996; 74: 246-257
- Are predictive energy expenditure equations accurate in cirrhosis?.Nutrients. 2019; 11: 334
- Variability in energy expenditure and its components.Curr Opin Clin Nutr Metab Care. 2004; 7: 599-605
- Ability of the Harris Benedict formula to predict energy requirements differs with weight history and ethnicity.Nutr Res. 2007; 27: 194-199
- Accuracy of four resting metabolic rate prediction equations: effects of sex, body mass index, age, and race/ethnicity.J Sci Med Sport. 2011; 14: 344-351
- A Biometric Study of Basal Metabolism in Man.Carneige Institute of Washingtom, Washington, DC1919 (Publication no. 279)
- A new predictive equation for resting energy expenditure in healthy individuals.Am J Clin Nutr. 1990; 51: 241-247
- Predicting basal metabolic rate, new standards and review of previous work.Hum Nutr Clin Nutr. 1985; 39: 5-41
- Basal metabolic rate studies in humans: measurement and development of new equations.Public Health Nutr. 2005; 8: 1133-1152
- Transection of the oesophagus for bleeding oesophageal varices.Br J Surg. 1973; 60: 646-649
- A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts.Hepatology. 2000; 31: 864-871
- World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.JAMA. 2013; 310: 2191-2194
- A language and environment for statistical computing Vienna.R Foundation for Statistical Computing, Austria2020 (Available from:)
- Statistical methods for assessing agreement between two methods of clinical measurement.Lancet. 1986; 1: 307-310
- 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
- Body composition, muscle function, and energy expenditure in patients with liver cirrhosis: a comprehensive study.Am J Clin Nutr. 2007; 85: 1257-1266
- Hyper- and hypometabolism are not related to nutritional status of patients on the waiting list for liver transplantation.Clin Nutr. 2014; 33: 754-760
- Comparison of measured and predicted energy expenditure in patients with liver cirrhosis.Asia Pac J Clin Nutr. 2014; 23: 197-204
- Effect of paracentesis on metabolic activity in patients with advanced cirrhosis and ascites.Scand J Gastroenterol. 2016; 51: 601-609
- Factors related to increased resting energy expenditure in men with liver cirrhosis.Eur J Gastroenterol Hepatol. 2016; 28: 139-145
- Estimation of basal metabolic rate in Chinese: are the current prediction equations applicable?.Nutr J. 2016; 15: 79
- Ethnic differences in body composition and the associated metabolic profile: a comparative study between Asians and Caucasians.Maturitas. 2010; 65: 315-319
- Relation between energy expenditure and body composition in man: specific energy expenditure in vivo of fat and fat-free tissue.Eur J Clin Nutr. 1988; 42: 301-305
- The contribution of body composition, substrates, and hormones to the variability in energy expenditure and substrate utilization in premenopausal women.J Clin Endocrinol Metab. 1992; 74: 279-286
- Variability in metabolic rate: biological sites of regulation.Int J Obes Relat Metab Disord. 1995; 19: S102-S106
- Prediction of resting energy expenditure from fat-free mass and fat mass.Am J Clin Nutr. 1992; 56: 848-856
- Metabolically active components of fat free mass and resting energy expenditure in nonobese adults.Am J Physiol Endocrinol Metab. 2000; 278: E308-E315
- Relationship of genetics, age, and physical fitness to daily energy expenditure and fuel utilization.Am J Clin Nutr. 1989; 49: 968-975
- Reexamination of the relationship of resting metabolic rate to fat-free mass and to the metabolically active components of fat-free mass in humans.Am J Clin Nutr. 1992; 55: 790-794
- Small organs with a high metabolic rate explain lower resting energy expenditure in African American than in white adults.Am J Clin Nutr. 2006; 83: 1062-1067
- Smaller size of high metabolic rate organs explains lower resting energy expenditure in Asian-Indian than Chinese men.Int J Obes. 2016; 40: 633-638
- Energy expenditure and substrate metabolism in patients with cirrhosis of the liver: effects of the pattern of food intake.Gut. 1995; 36: 110-116
- Hepatic energy and substrate metabolism: a possible metabolic basis for early nutritional support in cirrhotic patients.Nutrition. 1998; 14: 30-38
- Estimation of energy expenditure using prediction equations in overweight and obese adults: a systematic review.J Hum Nutr Diet. 2016; 29: 458-476
- Resting energy expenditure in patients with solid tumors undergoing anticancer therapy.Nutrition. 2006; 22: 609-615
- Measured versus calculated resting energy expenditure in critically ill adult patients. Do mathematics match the gold standard?.Minerva Anestesiol. 2015; 81: 272-282
- Harris-Benedict equation and resting energy expenditure estimates in critically iIll ventilator patients.Am J Crit Care. 2016; 25: e21-e29
- Body fat assessed from total body density and its estimation from skinfold thickness: measurements on 481 men and women aged from 16 to 72 years.Br J Nutr. 1974; 32: 77-97
- Evolving concepts on adjusting human resting energy expenditure measurements for body size.Obes Rev. 2012; 13: 1001-1014
- Human energy expenditure: advances in organ-tissue prediction models.Obes Rev. 2018; 19: 1177-1188
- Prognostic value of energy metabolism in patients with viral liver cirrhosis.Nutrition. 2002; 18: 229-234
- Nutrition status predicts survival in cirrhosis.Nutr Rev. 1996; 54: 217-219
Article info
Publication history
Published online: January 25, 2022
Accepted:
January 13,
2022
Received in revised form:
January 11,
2022
Received:
September 11,
2021
Footnotes
Author names in bold designate shared co-first authorship
Identification
Copyright
© 2022 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
