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Prevalence and Mechanisms of Malnutrition in Patients With Advanced Liver Disease, and Nutrition Management Strategies

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Malnutrition is prevalent among cirrhotic patients and is an important prognostic factor. Etiologic factors include hypermetabolism, malabsorption, altered nutrient metabolism, and anorexia. It is a challenge to manage nutrition in cirrhotic patients because of alterations to metabolic and storage functions of the liver; use of traditional assessment tools, such as anthropometric and biometric measures, is difficult because of complications such as ascites and inflammation. In addition to meeting macro- and micronutrient requirements, the composition and timing of supplements have been proposed to affect efficacy of nutrition support. Studies have indicated that branched chain aromatic acid can be given as therapeutic nutrients, and that probiotics and nocturnal feeding improve patient outcomes.

Section snippets

Prevalence of Malnutrition

Patients with chronic diseases frequently become malnourished; they have an inability to meet macronutrient and micronutrient requirements through oral intake.5 Inadequate intake and/or associated malabsorption alters body composition and diminishes biological functions.5 Parameters used to assess malnutrition in patients with liver disease include anthropometric and serum measurements and qualitative data on weight history and food intake.6, 7

Malnutrition is common in patients with advanced

Etiology of Malnutrition

The etiology of malnutrition is multifactorial and primarily related to reduced liver function; poor oral intake and complications of cirrhosis such as ascites and hepatic encephalopathy also contribute.

Nutrition Assessment

Because nutrition is correlated with outcome of patients with liver disease, it is important to accurately assess nutritional status and provide timely nutritional support. This task is challenging, due to the complications of altered rates of protein metabolism and presence of ascites and edema. The European Society of Clinical Nutrition and Metabolism (ESPEN) 2006 guideline recommends the use of the subjective global assessment (SGA), anthropometry analysis, or the handgrip strength test to

Nutrition Recommendations

Current nutritional recommendations aim to provide patients with cirrhosis with sufficient energy intake for daily activities, the increased energy requirements associated with liver disease, to prevent further protein catabolism for energy, and to meet nutritional requirements, based on recommended daily intake. The recommendations proposed in the literature reflect the higher nutritional needs of patients with advanced liver disease, who have impaired nutrient absorption, and altered micro-

What About Parenteral Nutrition?

Total parenteral nutrition (TPN) should be restricted to patients that have contraindications to oral or enteral nutrition and to situations whereby adequate oral or enteral caloric intake is not being met despite best efforts. Patients who receive parenteral nutrition are at risk for infections—particularly catheter-related infections. Patients with advanced liver disease are also at risk for infections, because of alterations in intestinal permeability and endotoxemia; the presence of foreign

Conclusions

Many different factors contribute to malnutrition in patients with chronic liver disease. Impaired hepatocyte functions disrupt the nutrient balance and metabolism, which (in addition to ascites, protein catabolism, and nutrient deficiencies) can lead to hepatic encephalopathy. Studies have shown that early detection and treatment of malnutrition is imperative to improve patient outcomes. In addition to current recommendations for macro- and micronutrient supplementation, the therapeutic uses

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    This article has an accompanying continuing medical education activity on page e18. Learning Objective—At the end of this activity, the learner will appreciate that morbidity and mortality is related to nutritional status in patients with advanced liver disease; recognize the multifactorial nature of malnutrition in patients with cirrhosis; and appreciate the importance of the liver in the many derangements of nutritional status in patients with cirrhosis.

    Conflicts of interest The authors disclose no conflicts.

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