Nutritional Assessment and Management for Patients with Chronic Liver Disease

Tae Hee Lee

doi:10.4166/kjg.2018.71.4.185

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Lee: Nutritional Assessment and Management for Patients with Chronic Liver Disease

Review Article

Korean J Gastroenterol 2018;71(4):185-191.

Published online: 4 October 2018

DOI: https://doi.org/10.4166/kjg.2018.71.4.185

Nutritional Assessment and Management for Patients with Chronic Liver Disease

Tae Hee Lee

Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea

Correspondence to: Tae Hee Lee, Department of Internal Medicine, Konyang University College of Medicine, 158 Gwanjeodong-ro, Seo-gu, Daejeon 35365, Korea. Tel: +82-42-600-9370, Fax: +82-42-600-9090, E-mail: green740@naver.com

Received 15 March 2018 Revised 5 April 2018 Accepted 5 April 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

When liver disease is severe, the prognosis can be worse if the patient is malnourished. Adequate nutritional support for patients with liver diseases can improve the patient's condition and prognosis. In the case of liver cirrhosis, malnutrition can occur due to a variety of causes, including poor oral intake, maldigestion, malabsorption, associated renal disease, and metabolic abnormalities. For a nutritional assessment, it is important to check the dietary intake, change in body composition, including anthropometry, and a functional assessment of muscle. Counselling and oral or enteral nutrition is preferred over parenteral nutrition as in other diseases. If esophageal varices are present, care should be taken when installing a feeding tube, but if there are ascites, percutaneous endoscopic gastrostomy is contraindicated because of the risk of complications. Calories of 30–35 kcal/kg/day and protein from 1.2 to 1.5 g/kg/day are appropriate. Protein restriction is unnecessary unless the hepatic encephalopathy is severe. A late evening snack and branched chain amino acids can be helpful. In the case of cholestasis, the supply of manganese and copper should be restricted. Sarcopenia in patients with liver cirrhosis is also prevalent and associated with the prognosis.

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Keywords: Malnutrition, Assessment, Cirrhosis, Calorie, Sarcopenia

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Fig. 1.

Royal Free Hospital-Nutritional Prioritizing Tool. Adapted from Arora et al.¹¹, with permission from J Hepatol.

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Fig. 2.

Royal Free Hospital Global Assessment scheme. BMI, body mass index; MAMC, mid- arm muscle cir-cumference; A, adequate; I, inadequate; N, negligible. Adapted from Morgan et al.²¹, with permission from Hepatology.

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Table 1.

Summary of Nutrition Screening Tools (Adapted from Tandon et al.¹⁰, with permission from Hepatology)

Screening tool (care setting)	Advantages	Disadvantages	Tool components
MUST (community)	High interrater reliability	Weight from fluid collections (ascites, peripheral edema) not accounted	BMI
	Content and predictive validity for length of hospital stay and mortality		Unplanned weight loss in past 3–6 months
		Disease severity not considered	Unplanned weight loss in past 3–6 months
	Practical		Acutely ill and unable to eat for ≥5 days
NRS-2002 (hospital)	Content and predictive validity	Weight from fluid collections (ascites, peripheral edema) not accounted	Weight loss
	Moderately reliable		Food intake
	Practical		BMI
	Considers disease severity		Disease severity
NUTRIC (critically ill)	Externally validated (n≥1,000 patients)	Interleukin-6 not widely available	Age
		Requires training	APACHE II and SOFA scores
		Classic nutrition parameters not considered	Comorbidities
		Classic nutrition parameters not considered	Days in hospital pre-ICU
			Interleukin-6
MNA (elderly [home-care programs, nursing homes, and hospitals])	Includes physical and mental components plus dietary questionnaire	Content validity not reported	GI symptoms
		Interrater reliability modest	Weight loss
		Weight from fluid collections (ascites, peripheral edema) not accounted	Mobility
	Predictive validity for adverse outcome, social functioning, mortality, and doctor visits		Psychological stress/acute disease
		Disease severity not considered	Neuropsychological problems
			BMI
	Practical
SNAQ (hospital)	Simple/practical	Weight from fluid collections (ascites, peripheral edema) not accounted	Unintentional weight loss
	Facilitates identification and treatment of malnourished inpatients		Decreased appetite
		Disease severity not considered	Use of supplements or tube feeding
MST (hospital)	Simple/practical	Weight from fluid collections (ascites, peripheral edema) not accounted	Unintentional weight loss
	Predictive validity for length of stay		Quantity of weight lost
	Excellent reliability	Disease severity not considered	Decreased appetite
	Highly sensitive
RFH-NPT (ambulatory hospital)	Simple/practical	Valid in population with cirrhosis only	Alcoholic hepatitis or tube feeding
	Cirrhosis-specific features	Impact of nutritional therapy based on screening score unknown	Considers fluid overload
	Excellent intraobserver and interobserver reproducibility		Dietary intake reduction
	Excellent intraobserver and interobserver reproducibility		Weight loss+option for assessing diuretic use
	Good external validity		Weight loss+option for assessing diuretic use
	Predictive of clinical deterioration and transplant-free survival

CNST (hospital)	Simple/practical	Weight from fluid collections (ascites, peripheral edema) not accounted	Unintentional weight loss
	Validated against SGA (sensitivity 67–73%, specificity 80–86%)		Dietary reduction
		Disease severity not considered
	High reliability	Symptoms not considered

MUST, malnutrition universal screening tool; NRS-2002, nutritional risk screening 2002; NUTRIC, nutrition risk in critically Ill; MNA, mini nutritional assessment; SNAQ, short nutritional assessment questionnaire; MST, malnutrition screening tool; RFH-NPT, royal free hospital-nutritional prioritizing tool; CNST, Canadian nutrition screening tool; BMI, body mass index; APACHE II, acute physiology and chronic health evaluation II; SOFA, sequential organ failure assessment; ICU, intensive care unit; GI, gastrointestinal.

Table 2.

Tools for Assessing the Oral Protein-energy Intake in End Stage Liver Disease (Adapted from Johnson et al.¹⁵, with permission from Nutr Clin Pract)

Assessment tool & method	Strengths	Limitations
Calorie count	Does not rely on patient's recall	Subjective
A healthcare professional calculates protein-energy intake based on foods consumed	Low cost	Portion sizes may not be standard or well documented
	No equipment required	Often relies on nursing staff to complete
Food diary	Low cost	Requires instruction by provider
Patient or caregiver records foods eaten	Does not require special equipment	Requires a higher level of literacy
Protein-energy intake is then calculated by a healthcare professional	Does not require special equipment	Subjectivity may lead to inaccuracies
	Can be very accurate	Typically underestimates energy intake
		Time-consuming for provider to analyze intake
Food frequency questionnaire	Low cost	May not represent foods typically consumed
Participant is given a list of foods/beverages and indicates how frequently these foods are consumed	Quick	High level of participant literacy required
		Does not provide data on portion sizes or actual protein-energy intake

24-hour recall	Low cost	May be inaccurate in those with poor memory or encephalopathy
Participant recalls all foods and beverages consumed over the previous 24 hours	Quick
	No equipment required	Under-reporting of portions and food items consumed may occur in women, those with body issues, or those who are overweight
Used to estimate protein-calorie intake

Table 3.

Summary of Nutritional Management in Patients with End Stage Liver Disease

General

Stepwise approach: counseling, supplements, tube feeding, parenteral nutrition

Adequate energy intake (total energy 25–40 kcal/kg/day, non-protein energy 25 kcal/kg/day)

Use indirect calorimetry if available

Enough protein (1.0–1.5 g/kg/day) without restriction

Avoid refeeding syndrome

Oral diet

Small/frequent meals

Bedtime snack or late evening meal (PM9-AM7)

High protein

Avoidance of skipping meals

≤2,000 mg sodium daily if ascites/edema present

Enteral nutrition

Initiate if unable to meet protein-energy needs via oral diet

Standard, energy-dense formula

Nasoenteral tube precautions

Percutaneous gastrostomy tube relatively contraindicated

Aspiration precautions

Parenteral nutrition

Indicated only if nutrition needs cannot be met via oral and enteral routes

Monitor glucose levels closely

If hyperglycemia present, limit glucose to 2–3 g/kg/d

≤1 g/kg/d lipids

Limit manganese and copper in setting of cholestasis

Cyclic regimen recommended

Concentrated solution to prevent fluid overload

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