nutritional assessment in chronic liver disease

Shaimaa Elkholy, M.D. Cairo University

Nutritional assessment in chronic liver disease

Shaimaa ElKholy, M.DCairo University, Egypt


Agenda:

• Introduction.• Pathogenesis of malnutrition in CLD.• Goals of nutritional assessment.• Steps of nutritional assessment.• Nutrition guidelines.• Summary and recommendations.


Introduction:

• Protein energy malnutrition (PEM) is a common complication of liver cirrhosis, it has been found to increase morbidity and mortality in these patients.

• In patients with liver cirrhosis PEM about 65%–90% of decompensated 20% of compensated liver cirrhosis.


Introduction:

• In liver transplantation PEM has been reported in 100% of patients prior to transplantation.

• Malnourishment was found to be an independent risk factor for morbidity and mortality in patients following liver transplantation.


Pathogenesis:

• Multifactorial.• Protien, CHO, and lipid metabolism are all

affected by liver disease. • Contributing factors:Inadequate dietary intakeImpaired digestion Impaired Absorption


Impaired digestion

Altered metabolism Impaired absorption

In adequate intake


Decreased intake*Anorexia

*Nausea*Encephalopathy *Gastritis *Ascites*A sodium restricted diet

*Concurrent alcohol consumption

Malabsorption and Maldigestion * Bile salt deficiency, * Bacterial overgrowth* Altered intestinal motility * Portal hypertensive changes to the intestine* Increased intestinal permeability * Pancreatic insufficiency


Cirrhosis represents an accelerated state of starvation (hypermetabolism)

loss of protein⇩ Synthesis of urea and hepatic proteins.⇩ Intestinal protein absorption⇧ Urinary nitrogen excretion Lowe ratio of BCAA/ AAA.

Abnormal CHO metabolismInsulin resistanceImpaired gluconeogenesis Reduced glycogen stores

lipids are preferentially oxidized for energy


Goals of nutritional assessment

• Identify nutritional risk that influences morbidity and mortality and which may be modifiable with targeted nutritional therapy.

• Determine the macronutrient (energy, protein, water) and micronutrient (electrolytes, minerals, vitamins, trace elements) state of a given individual.

• Body composition and muscle function analysis add supplemental information.


Nutritional assessment

There is no gold standard rule for the assessment of the nutritional of status in patients with cirrhosis


Steps for nutritional assessment

• Patients with compensated cirrhosis are more likely to be similar to a healthy population on clinically or laboratory basis.

• Nutritional assessment is generally more detailed in patients with decompensated disease

• Standard nutrition assessment tools have limitations with decompensated liver cirrhosis.



• Detailed nutritional assessment in all patients is not required.

• A Staged approach is suggested beginning

with a complete history and physical examination and proceeding with more detailed testing if needed.



• History • Physical examination• Subjective global

assessment• Laboratory evaluation• Anthropometry• Miscellaneous tests


1.History

B) Dietary intake the 24 hour dietary recall The patient recounts meals and snacks on a typical day (intake of food from each of the food groups plus nutritional supplements)Alcohol intake should also be quantified

A) Weight history recent weight loss (two weeks)weight lost over six monthsUnintentional wt loss of >10 % over six months is considered severeless accurate in patients with decompensated cirrhosis

C) Gastrointestinal symptoms AnorexiaNauseaVomitingdiarrhea, and steatorrheaPresence > two week with a limitation in nutrient intake are concerning.


D) Liver disease The nature and severity of liver disease: Compensated decompensated liver (Child Pugh score)(MELD) disease.

E) Micronutrient deficiency Features suggestive of micronutrient deficiency e.g. Dermatitis (zinc, vitamin A, niacin)Night blindness or photophobia (vitamin A) Burning of the mouth or tongue (vitamin B12 folate) Paresthesias (thiamine, pyridoxine).


• Body mass index (BMI). • Oedema as ankle, sacral edema or

ascites.• Muscle wasting as in quadriceps and

deltoids.• Loss of subcutaneous fat ( triceps and

chest).• Micronutrient deficiency e.g. pallor

(iron deficiency), hyperkeratosis (vitamin A)…..etc.

2.Physical examination


• Simple bedside tool which assesses nutritional status based on features of the history and physical examination.

• Five components of the SGA : Weight loss. Change in dietary intake. Presence of gastrointestinal symptoms. Functional capacity. Metabolic demand.

3 .Subjective global assessment


A.History1. Weight changeOverall loss in past 6 months: amount = # ___________ kg; % loss = # ____________________Change in past 2 weeks: ___________________ increase, ___________________ no change, ___________________ decrease.

2. Dietary intake change (relative to normal)___________No change, ___________Change ________________duration = # ____________________ weeks ________________type: __________ suboptimal liquid diet, _________ full liquid diet __________ hypo caloric liquids, _________ starvation.

3. Gastrointestinal symptoms (that persisted for >2 weeks)__________none, __________nausea, __________vomiting, __________diarrhea, __________anorexia.

4. Functional capacity___________ No dysfunction (e.g., full capacity), ___________ Dysfunction _________________ duration = # _______________ weeks. _________________ type: __________________working sub optimally, __________________ambulatory, __________________bedridden.

5. Disease and its relation to nutritional requirementsPrimary diagnosis (specify) _____________________________________________________________________Metabolic demand (stress) : ____________ no stress, _________________low stress,____________moderate stress,


B. Physical (for each trait specify: 0 = normal, 1+ = mild, 2+ = moderate, 3+ = severe) :

# __________________________________loss of subcutaneous fat (triceps, chest)# __________________________________muscle wasting (quadriceps, deltoids)# __________________________________ankle edema# __________________________________sacral edema# __________________________________ascites

C. SGA rating (select one) :

________________________A = Well nourished________________________B = Moderately (or suspected of being) malnourished________________________C = Severely malnourished.


• Plasma proteins (albumin, pre-albumin, transferrin and coagulation factors).

• Fat soluble vitamins in alcoholic liver disease and cholestatic liver disease (primary biliary cirrhosis).

• Water soluble vitamins and minerals as thiamine is common in alcoholic liver disease.

• Creatinine ( marker of protein stores) In Cirrhosis there is hepatic creatine synthesis, muscle mass, and tubular creatinine secretion.

4 .Laboratory evaluation


• Bedside tool used to assess body fat and lean tissue stores that is largely unaffected by salt and water overload that indirectly estimates body composition.

5 .Anthropometry • Most of RCT

showed that anthropometry:

Improved the detection of malnutrition.

Highly correlates with morbidity &mortality.


Triceps skin fold thickness (TSFT): using skin fold caliber


Steps for measuring MAC (mid arm circumference)


The tape is wrapped around the mid-arm mark.


DEXA scan: Retains utility in the

diagnosis of osteoporosis and osteomalacia, particularly in patients with cholestatic liver disease.

6 .Miscellaneous


Bioelectrical impedance analysis (BIA) Performed by applying electrodes to one arm and one leg or by

standing on a special scale. Impedance is proportional to the length of the conductor and

inversely related to the cross-sectional area of the conductor. Accuracy in placement of electrodes is essential because even small

variations can cause relatively large errors in the measurement of impedance and corresponding errors in the estimate of body water.

A variety of formulas have been developed to convert the impedance, which measures body water, into an estimate of fat content.


Measuring BMI, fat% ,muscle% and visceral fat using body fat monitor.

Data regarding height ,age & sex is entered.


The Body Fat Monitor with Scale sends a safe, low-level electrical current through the body to calculate the amount of body fat tissue. This is known as the Bioelectrical Impedance (BI) then Your visceral fat ,muscle percentages are automatically calculated.


Hand grip: Several studies have confirmed the importance of muscle strength as a predictive factor for

malnutrition .


ESPEN Guidelines on Enteral Nutrition: CLD (steato hepatitis)

• General : Use simple bedside methods such as the SubjectiveGlobal Assessment (SGA) or anthropometry to identify patients at risk of undernutrition.

• Recommended energy intake: 35–40 kcal/kg BW/d

• Recommended protein intake: 1.2–1.5 g/kgBW/d


ESPEN Guidelines on Enteral Nutrition: CLD (liver cirrhosis)

• General : Use simple bedside methods such as the Subjective Global Assessment (SGA) or anthropometry to identify patients at risk of undernutrition.

• Body cell mass measured by (BIA) to quantitate undernutrition, despite some limitations in patients with ascites.

• Recommended energy intake: 35–40 kcal/kg BW/d• Recommended protein intake: 1.2–1.5 g/kgBW/d


Nutritional support in liver cirrhosis

Compensated cirrhosis: 25–35 kcal/kg/d 1.0–1.2 g/kg/d Inadequate intake or malnutrition: 35–40 kcal/kg/d 1.5 g/kg/d Encephalopathy I–II: 35–40 kcal/kg/d 0.5- 1 g/kg/d if protein intolerant: vegetable protein or BCAA

supplement Encephalopathy III–IV: 35–40 kcal/kg/d 0.5 g/kg/d BCAA-enriched amino acid solution is recommended


ESPEN Guidelines on Enteral Nutrition: pre transplant & surgery

• General : Use simple bedside methods such as the Subjective Global Assessment (SGA) or anthropometry to identify patients at risk of undernutrition.

• Body cell mass measured by (BIA) to quantitate undernutrition, despite some limitations in patients with ascites.


ESPEN Guidelines on Enteral Nutrition: pre transplant & surgery

• Preoperative Follow recommendations for cirrhosis.

• Postoperative Initiate normal food/enteral nutrition within12–24 h postoperatively.

• Recommended energy intake: 35–40 kcal/kgBW/d

• Recommended protein intake: 1.2–1.5 g/kgBW/d


Take home message


PEM is highly prevalent among patients with liver cirrhosis is directly correlated to the

degree & severity of the disease.Complications of liver cirrhosis are highly

correlated to degree of malnutrition.There are several tools for nutritional

assessment in cirrhotic but yet there is no gold standard one.

SGA is a simple bedside tool commonly used. yet anthropometric measures e.g. TSFT

&MAC are showing higher sensitivity & specificity.


Thank you

nutritional assessment in chronic liver disease

Health & Medicine