Elsevier

Clinics in Liver Disease

Volume 16, Issue 1, February 2012, Pages 95-131
Clinics in Liver Disease

Malnutrition in Cirrhosis: Contribution and Consequences of Sarcopenia on Metabolic and Clinical Responses

https://doi.org/10.1016/j.cld.2011.12.009Get rights and content

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Malnutrition in liver disease: definitions

There is wide heterogeneity in the definition of malnutrition in cirrhosis, primarily because adult malnutrition is not well defined. In children, malnutrition is clearly defined as predominantly protein malnutrition or kwashiorkor and combined protein and calorie malnutrition or marasmus. In humans, most proteins are located in the skeletal muscle,44, 45, 46, 47 and we have, therefore, defined clinical adult protein malnutrition as primarily skeletal muscle loss. Energy malnutrition is more

Methods to assess malnutrition in cirrhosis

As previously stated, most publications on malnutrition in cirrhosis use heterogeneous definitions. Standard nutritional assessment instruments use laboratory tests, such as prothrombin time; albumin; prealbumin; transferrin; creatinine height index; and on tests of immune function, such as the delayed-type hypersensitivity reactions.48, 49, 50 Because end-stage liver disease or cirrhosis confound the common measures of nutritional status, their utility in these patients is reduced. Patients

Prevalence of malnutrition in cirrhosis

A high prevalence of malnutrition has been reported in patients with cirrhosis in studies in which visceral protein status and immunologic measures are included in the nutritional assessment.48, 68, 69 The prevalence of nutritional disorders is lower when malnutrition is diagnosed by anthropometric measures only.54, 55 Differences in the cause and severity of disease also affect the estimated prevalence of malnutrition in cirrhosis.48, 70, 71, 72, 73 A review of studies published that examined

Severity of liver disease worsens sarcopenia

Malnutrition has also been related to the severity of liver disease as estimated by Child’s score.73 Several modifications of the original Child’s score have been used, including the Child-Turcotte, Campbell Child, and Pugh-Child scoring systems.80 In the Pugh modification, the nutritional status was replaced by prothrombin time; the rationale for this was that the nutritional assessment used in the other versions had a significant subjective evaluation, whereas the prothrombin time in

Clinical implications of malnutrition in cirrhosis

For practical clinical purposes, the impact of malnutrition in cirrhosis on outcome can be examined by the effect of skeletal muscle loss on survival and complications of cirrhosis. With the availability of liver transplantation, aggressive intensive care, antibiotics, renal support, and endoscopic interventions to prevent and treat the complications of cirrhosis, there is a resurgence of interest in the nutritional management of these patients. Several studies have consistently shown that

Pathogenesis and mechanisms of sarcopenia in cirrhosis

Because sarcopenia is the major contributor to malnutrition, functional status, and outcomes in cirrhosis, an understanding of the biochemical and cellular mechanisms that result in loss of muscle mass is critical to identify therapeutic targets. Initial works in understanding the metabolic alterations in cirrhosis were based on isotopic tracer methodology.113 Despite initial enthusiasm, these were predominantly descriptive studies; and only recently, the advances in myology, gerontology, and

Aging patients with cirrhosis

As the global population ages, this contributes to the progressive worsening of sarcopenia. It is estimated that after the age of 50 years, approximately 1% of skeletal muscle loss occurs per year.148, 149 The impact and interaction of sarcopenia of aging and cirrhosis are not known. The adverse effects of both of these processes on muscle mass and function may be exponential, contributing to an urgent need to increase our understanding of the mechanisms and identification of therapies.

Posttransplanted patients with cirrhosis

Pretransplant malnutrition, specifically sarcopenia, adversely impacts the perioperative and immediate posttransplant outcomes (Table 5). Additionally, pretransplant sarcopenia is associated with worse outcomes after liver transplantation.5, 17 It is thought that liver transplantation is curative for cirrhosis. However, it must be reiterated that this option is available only to a minority of patients. Furthermore, posttransplant metabolic syndrome and the attendant insulin resistance adds to

Therapeutic options

Given the human data that suggest that cirrhosis is a state of accelerated starvation,155 several nutrient interventions have been tried with limited success in long-term improvement in protein or energy metabolism.156, 157 Several hormonal alterations have resulted in interventions that use anabolic androgens, IGF, and growth hormone with no benefit and several adverse effects.158, 159, 160, 161 Current studies underway on understanding the mechanisms of alteration in protein and fat

Nutritional supplementation

Because skeletal muscle is the major whole body protein store, with a reduction in muscle mass, whole body protein content is lower. Increased protein intake has been demonstrated to be safe, well tolerated, and beneficial in patients with cirrhosis, but the long-term anabolic effects on muscle mass and function have not yet been established.33, 156, 162, 163, 164, 165, 166 Several nutritional interventions have been examined that have focused on 2 specific areas: decrease the intermeal

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References (192)

  • G. Marchesini et al.

    Branched-chain amino acid supplementation in patients with liver diseases

    J Nutr

    (2005)
  • M. Charlton

    Branched-chain amino acid enriched supplements as therapy for liver disease

    J Nutr

    (2006)
  • M. Conchillo et al.

    Insulin-like growth factor I (IGF-I) replacement therapy increases albumin concentration in liver cirrhosis: results of a pilot randomized controlled clinical trial

    J Hepatol

    (2005)
  • S. Dasarathy et al.

    Sarcopenia associated with portosystemic shunting is reversed by follistatin

    J Hepatol

    (2011)
  • G. Gayan-Ramirez et al.

    Biliary cirrhosis induces type IIx/b fiber atrophy in rat diaphragm and skeletal muscle, and decreases IGF-I mRNA in the liver but not in muscle

    J Hepatol

    (1998)
  • S. Dasarathy et al.

    Inhibition of aromatase improves nutritional status following portacaval anastomosis in male rats

    J Hepatol

    (2006)
  • H.J. Krzywicki et al.

    Body composition of a military population, Fort Carson, 1963. I. Body density, fat, and potassium 40

    Am J Clin Nutr

    (1967)
  • H.J. Krzywicki et al.

    Human body density and fat of an adult male population as measured by water displacement

    Am J Clin Nutr

    (1967)
  • S.R. DiCecco et al.

    Assessment of nutritional status of patients with end-stage liver disease undergoing liver transplantation

    Mayo Clin Proc

    (1989)
  • S.J. O’Keefe et al.

    Malnutrition and immuno-incompetence in patients with liver disease

    Lancet

    (1980)
  • P.J. Thuluvath et al.

    Evaluation of nutritional status by using anthropometry in adults with alcoholic and nonalcoholic liver disease

    Am J Clin Nutr

    (1994)
  • M. Pirlich et al.

    Bioelectrical impedance analysis is a useful bedside technique to assess malnutrition in cirrhotic patients with and without ascites

    Hepatology

    (2000)
  • A.M. Madden et al.

    The potential role of dual-energy x-ray absorptiometry in the assessment of body composition in cirrhotic patients

    Nutrition

    (1997)
  • M.Y. Morgan et al.

    Two-component models are of limited value for the assessment of body composition in patients with cirrhosis

    Am J Clin Nutr

    (2006)
  • A.M. Madden et al.

    A comparison of skinfold anthropometry and bioelectrical impedance analysis for measuring percentage body fat in patients with cirrhosis

    J Hepatol

    (1994)
  • C.L. Mendenhall et al.

    Protein-calorie malnutrition associated with alcoholic hepatitis. Veterans Administration Cooperative Study Group on Alcoholic Hepatitis

    Am J Med

    (1984)
  • L. Caregaro et al.

    Malnutrition in alcoholic and virus-related cirrhosis

    Am J Clin Nutr

    (1996)
  • C. Roongpisuthipong et al.

    Nutritional assessment in various stages of liver cirrhosis

    Nutrition

    (2001)
  • M.E. Lehnert et al.

    Estimation of body water compartments in cirrhosis by multiple-frequency bioelectrical-impedance analysis

    Nutrition

    (2001)
  • P.R. Mills et al.

    Assessment of nutritional status and in vivo immune responses in alcoholic liver disease

    Am J Clin Nutr

    (1983)
  • F. Durand et al.

    Assessment of the prognosis of cirrhosis: Child-Pugh versus MELD

    J Hepatol

    (2005)
  • M. Deschenes et al.

    Lack of relationship between preoperative measures of the severity of cirrhosis and short-term survival after liver transplantation

    Liver Transpl Surg

    (1997)
  • P. Tessari

    Protein metabolism in liver cirrhosis: from albumin to muscle myofibrils

    Curr Opin Clin Nutr Metab Care

    (2003)
  • G. Bianchi et al.

    Update on nutritional supplementation with branched-chain amino acids

    Curr Opin Clin Nutr Metab Care

    (2005)
  • I. Bilbao et al.

    Predictive factors for early mortality following liver transplantation

    Clin Transplant

    (2003)
  • O. Selberg et al.

    Identification of high- and low-risk patients before liver transplantation: a prospective cohort study of nutritional and metabolic parameters in 150 patients

    Hepatology

    (1997)
  • E. Kalaitzakis et al.

    Gastrointestinal symptoms in patients with liver cirrhosis: associations with nutritional status and health-related quality of life

    Scand J Gastroenterol

    (2006)
  • E. Kalaitzakis et al.

    Malnutrition and diabetes mellitus are related to hepatic encephalopathy in patients with liver cirrhosis

    Liver Int

    (2007)
  • E.J. Huisman et al.

    Protein energy malnutrition predicts complications in liver cirrhosis

    Eur J Gastroenterol Hepatol

    (2011)
  • M. Merli et al.

    Cirrhotic patients are at risk for health care-associated bacterial infections

    Clin Gastroenterol Hepatol

    (2010)
  • M. Merli et al.

    Nutritional status: its influence on the outcome of patients undergoing liver transplantation

    Liver Int

    (2010)
  • L.G. Ferreira et al.

    The impact of nutrition on cirrhotic patients awaiting liver transplantation

    Curr Opin Clin Nutr Metab Care

    (2010)
  • A.J. Montano-Loza et al.

    Sarcopenia is associated with mortality in patients with cirrhosis

    Clin Gastroenterol Hepatol

    (2011)
  • C.D. Tsien et al.

    Late evening snack - exploiting a period of anabolic opportunity in cirrhosis

    J Gastroenterol Hepatol

    (2011)
  • Nutritional status in cirrhosis. Italian multicentre cooperative project on nutrition in liver cirrhosis

    J Hepatol

    (1994)
  • J. Lata et al.

    Factors participating in the development and mortality of variceal bleeding in portal hypertension–possible effects of the kidney damage and malnutrition

    Hepatogastroenterology

    (2006)
  • F. Gunsar et al.

    Nutritional status and prognosis in cirrhotic patients

    Aliment Pharmacol Ther

    (2006)
  • M. Kato et al.

    Preferential use of branched-chain amino acids as an energy substrate in patients with liver cirrhosis

    Intern Med

    (1998)
  • E.T. Tsiaousi et al.

    Malnutrition in end stage liver disease: recommendations and nutritional support

    J Gastroenterol Hepatol

    (2008)
  • M. Zaratiegui et al.

    IGF1 gene transfer into skeletal muscle using recombinant adeno-associated virus in a rat model of liver cirrhosis

    J Physiol Biochem

    (2002)
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