COMMENTARY

Advice for Combating Frailty's Fatal Impact in Liver Disease

Rowen K. Zetterman, MD

Disclosures

January 22, 2018

Targeting Malnutrition in Patients With Cirrhosis

Malnutrition, a contributor to frailty, is present in more than one half of patients with end-stage liver disease[25,26] and worsens as liver disease progresses. Reasons for malnutrition include poor dietary intake related to anorexia, loss of taste, ascites, evidence of fat malabsorption from disorders such as chronic pancreatitis or sprue, and greater energy expenditure and altered hepatic metabolism. In an evaluation of patients with cirrhosis (of which 71% of cases were due to ethanol use), 95% of patients with Child-Pugh class C had evidence of malnutrition.[27] Greater rates of malnutrition are more likely to occur in females than in males.

Significant malnutrition is predictive of in-hospital mortality and complications associated with end-stage liver disease.[27] Therefore, assessment of malnutrition in patients with cirrhosis is crucial.[28] Malnutrition is especially common in alcoholic cirrhosis, is an independent predictor of mortality, and may be difficult to determine from clinical observation alone.[29] Given that fluid overload, peripheral edema, and ascites are typically present in advanced liver disease, body mass index is a poor indicator of malnutrition in patients with cirrhosis. To evaluate for evidence of malnutrition, anthropometric assessment should be used.[29]

Fasting should be limited in patients with cirrhosis.[30] Even patients with encephalopathy need adequate protein intake[31] using vegetable protein sources, or branched-chain amino acid supplementation for those intolerant of dietary protein.

Providing a late-night snack may also reduce malnutrition and frailty in cirrhosis.[30] In a study comparing cirrhotic patients who were supplemented with either a daytime or a nighttime (midnight to 7 AM) snack, researchers found that those given the latter developed greater total body protein than those who were supplemented during the day.

Assessing nutritional status in patients awaiting liver transplantation is crucial,[32] because malnutrition is associated with a greater likelihood of infection, longer hospitalization, and reduced graft and patient survival.[26]

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