Malnutrition in Cirrhosis: Frequent but Overlooked

Potential conflict of interest: Nothing to report. See Article on Page 1790 The prevalence of malnutrition is estimated to be 46% in Child‐Turcotte‐Pugh (CTP) class A cirrhosis patients, 84% in CTP class B cirrhosis patients, and 95% in CTP class C cirrhosis patients.1 Nutritional status is an important predictor of morbidity and mortality in patients with cirrhosis. However, it is often overlooked during the management of concurrent acute medical issues and due to the lack of standardized management guidelines. Malnutrition is also associated with higher rates of hepatic decompensation, ascites, hepatic encephalopathy, variceal bleeding, and poor wound healing. Poor nutrition can further complicate debility, and it portends worse postoperative outcomes in a liver transplantation (LT) candidate. Although there is increased recognition of poorer outcomes after LT due to malnutrition, there are limited data on management strategies.2 The European Association for the Study of the Liver and the International Society of Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) proposed guidelines for energy and nutrient requirements in patients with cirrhosis. The recommendations include 35‐40 kcal/kg/day in nonobese patients, 1.2‐1.5 g/kg of protein intake per day evenly distributed with a snack prior to bedtime, complex carbohydrates, nutrient‐dense plant‐based foods, and supplementation with a multivitamin and/or branched‐chain amino acids.3 In the general population, validated malnutrition screening tools (MSTs) include the Nutritional Risk Screening 2002 (NRS‐2002), the Malnutrition Universal Screening Tool, and the Royal Free Hospital–Nutritional Prioritizing Tool (RFH‐NPT).4 In patients with liver disease, the RFH‐NPT score has been used but is not yet validated. The RFH‐NPT score incorporates several factors, including volume overload, body mass index, recent diet and weight fluctuations, and stratifies the risk for malnutrition.5 The Liver Disease Undernutrition Screening Tool is another MST that uses oral intake, weight loss, loss of subcutaneous fat or muscle mass, volume overload, and functional status.6 In this issue, Reuter et al.7 performed a study in 3 phases that included awareness education as an intervention to involve dietary professionals earlier in the care of hospitalized patients with cirrhosis. In the retrospective phase of the study, they collected data on the frequency of dietary referrals placed upon admission at 2 transplant centers, nutritional assessment using the RFH‐NPT scoring system, length of stay (LOS), and readmission rates. Nutrition was inadequately addressed in most hospitalized patients with acute hepatic decompensation, and it was further jeopardized because of extended periods of nil per os, unpalatable diet, and insufficient nutrient supplementation. Increased hospital LOS and higher 90‐day readmission rates were noted in the retrospective phase. In the intervention phase, a brief educational module based on the ISHEN guidelines was provided periodically to the medical professionals along with verbal reminders and poster displays to improve the management of nutrition. In the prospective phase, the dieticians used the RFH‐NPT scoring system to assess malnutrition and to evaluate outcomes due to the intervention. Both retrospective and prospective groups had comparable volumes of patients with low/moderate risk versus high‐risk malnutrition. The prospective group received a diet high in protein/night‐time snacks (18.6% versus 10.3%; P = 0.02) and vitamin supplementation (74.5% versus 58.8%; P = 0.005). The study demonstrated that the educational intervention led to an increase in the number of nutrition consults (74.5% versus 40.1%; P < 0.001), which allowed for improved nutritional management and significantly reduced hospital LOS (5.7 versus 8.4 days; P = 0.004). Furthermore, the prospective group had lower 90‐day readmission rates compared with the retrospective group (28.4% versus 39.4%; P = 0.04). The current study by Reuter et al.7 demonstrated good short‐term outcomes due to early nutritional evaluation and intervention in hospitalized patients with cirrhosis, but a standardized approach for nutritional assessment is not yet available. Although this study evaluated important quality measures (LOS and 90‐day readmission rates), the costs and recruitment of staff for the rigorous employment of this strategy could be challenging. Future research studies should evaluate the following: Standardized tools for assessment and management of malnutrition. Early use of enteral or parenteral nutrition. Use of body composition measurements to assess volume overload, sarcopenia, and lipopenia. Validated MSTs for the outpatient setting.8 Various studies have proposed the use of alternate measures to assess body mass or sarcopenia, such as dual‐energy X‐ray absorptiometry or bioelectrical impedance analysis, with favorable results. Individuals with cirrhosis have an increased caloric and protein requirement due to their hypercatabolic state. Nonalcoholic fatty liver disease (NAFLD) is often associated with obesity and may require moderate calorie restriction (500‐800 kcal/day) while maintaining adequate protein intake (>1.5 g/kg ideal body weight/day).3 Therefore, obese sarcopenic patients with NAFLD‐related cirrhosis should be studied separately from their nonobese counterparts. It is evident that nutrition plays a major role in the recovery of hospitalized patients with decompensated cirrhosis. Despite the awareness about its significance, malnutrition is frequently underscreened and not aggressively managed in routine practice. The educational intervention proposed in the study by Reuter et al.7 provides an impetus to develop judicious strategies to combat malnutrition in cirrhosis. Appropriate nutritional counseling and interventions in this otherwise sick population would not only improve health outcomes but would also improve health care economics.