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This article has an accompanying continuing medical education activity on page e18. Learning ObjectiveAt the end
of this activity, the learner will appreciate that morbidity and mortality is related to nutritional status in patients with
advanced liver disease; recognize the multifactorial nature of malnutrition in patients with cirrhosis; and appreciate the
importance of the liver in the many derangements of nutritional status in patients with cirrhosis.
Prevalence of Malnutrition
Patients with chronic diseases frequently become malnourished; they have an inability to meet macronutrient and
micronutrient requirements through oral intake.5 Inadequate
intake and/or associated malabsorption alters body composition and diminishes biological functions.5 Parameters used to
assess malnutrition in patients with liver disease include anthropometric and serum measurements and qualitative data on
weight history and food intake.6,7
Malnutrition is common in patients with advanced liver
disease; the prevalence is reported to be 50%90% among cirrhotic patients.711 In a study of 300 patients, more than 75% of
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CHEUNG ET AL
increased with malnutrition; in the same study, 65% of malnourished patients developed complications compared with
11% of well-nourished patients.13
After liver transplantation, malnutrition has been associated
with higher rates of infectious complications, longer stays in
the intensive care unit, and higher mortality.6,8 Additionally,
patients with more severe malnutrition have longer postoperative hospital stays.6
Etiology of Malnutrition
The etiology of malnutrition is multifactorial and primarily related to reduced liver function; poor oral intake and
complications of cirrhosis such as ascites and hepatic encephalopathy also contribute.
Hypermetabolism
Resting energy expenditure (REE) is the amount of
energy an individual uses to perform vital organ functions, free
of activity and digestion.14 A commonly used predictive equation for REE is the Harris Benedict Equation, which factors
weight, height, and sex in the calculation. Whereas most cirrhotic patients have a REE that is similar to predicted values,
15%30% of patients are hypermetabolic.15,16 Hypermetabolism is
defined as REE 120% compared with the predicted value.15,16 The
causes of hypermetabolism are unclear; a recent study of 268
patients did not associate hypermetabolism with sex, etiology,
Malabsorption
There are multiple mechanisms that can lead to malabsorption of nutrientsparticularly of fatin cirrhotic patients (Figure 1). One complication that affects nutrient absorption in patients with cirrhosis is portosystemic shunting. As
cirrhosis progresses, portosystemic shunting causes nutrients to
bypass the liver, without metabolic processing.2,23 In addition,
many patients with cirrhosis that is secondary to alcohol abuse
have chronic pancreatitis, which contributes to malabsorption.
An analysis of autopsy results found that 18% of cirrhotic
patients also had chronic pancreatitis.24
February 2012
Anorexia
As in other chronic illnesses, anorexia makes a significant contribution to malnutrition. Anorexia can be caused by
physical symptoms of discomfort such as nausea, bloating,
fatigue, and vomiting. Patients with ascites often experience
early satiety resulting from the mechanical effects of ascitic
fluid, which compress the stomach.35
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Additionally, loss of appetite can be related to the up-regulation of inflammation and appetite mediators.16,36 Levels of
tumor necrosis factor (TNF)- and leptin correlate with satiety
and energy expenditure; patients with cirrhosis have increased
serum levels of this cytokine.37 Tumor necrosis factor- might
affect appetite and metabolism by acting on the central nervous
system, altering the release and function of neurotransmitters.38
Leptin is an appetite-regulating hormone that is secreted by
adipose tissue.39 Cirrhotic patients had a 2-fold increase in
fasting levels of leptin compared with healthy individuals; this
might contribute to anorexia in these patients.32
Ghrelin, which stimulates appetite, is produced primarily by
the stomach. Although some cirrhotic patients have been observed to have abnormal fasting levels of this hormone, the
relationship between ghrelin and anorexia is unclear; some
studies have reported increases and others reported decreases.32,40 Changes in ghrelin levels might be related to the
systemic response to liver disease and state of anorexia or a
consequence of the livers role in hormone regulation.32,40
Aside from hormonal influences and physical discomfort,
disinterest in food can result from dietary restrictions and taste
alterations. Dietary limitations, such as sodium restriction for
ascites management, preoperative fasting, and limitation of
protein intake for severe hepatic encephalopathy can reduce
food variety; many patients do not accept the allowable foods.
Although taste alterations have been commonly attributed to
micronutrient deficiencies, researchers have questioned whether
they are a consequence of cirrhosis itself.41,42
It is also important to consider alcohol-related anorexia.
According to the American Liver Foundation, 10%20% of
chronic users of alcohol develop cirrhosis. Poor and irregular
feeding is common among patients with alcoholic cirrhosis.
Before hospital admission, 53% of alcoholic patients reported
anorexia, 40% reported irregular feeding, and 36% ate only 1
meal per day.43 In a study of middle-income patients with
alcoholic cirrhosis, although their energy intake was similar to
that of nonalcoholics, their overall intake of nutrients was
lower, because they acquired most of their energy from alcohol
rather than nutrient-rich foods.44 The socioeconomic status of
patients can also affect oral intake; patients who have alcoholic
cirrhosis and low socioeconomic status are prone to poor and
irregular feeding. As a result, they develop nutrient deficiencies,
such as low serum levels of folate, B12, and B6, and macronutrient deficiencies.45
Micronutrient Status
Patients with advanced liver disease have an increased
risk of micronutrient deficiencies that arise from anorexia,
diuretic use, fat malabsorption, and hepatitis C. Because patients with ascites have restricted intake of animal protein and
are treated with diuretics, they commonly acquire zinc deficiency.46 Similarly, magnesium deficiency can result from decreased oral intake of nutrients and use of diuretics.
Although rates of deficiencies in fat-soluble vitamins vary
among studies, vitamin A and vitamin D deficiencies are most
commonly reported.47 More than 90% of patients with cirrhosis
have some level of vitamin D deficiency and 29% have severe
vitamin D deficiency (17.5 nmol/L).48 Low serum levels of
fat-soluble vitamins can impair absorption of other nutrients,
such as vitamin D and calcium. In patients with primary biliary
cirrhosis (PBC), reduced concentrations of intraluminal bile
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CHEUNG ET AL
Nutrition Assessment
Because nutrition is correlated with outcome of patients with liver disease, it is important to accurately assess
nutritional status and provide timely nutritional support. This
task is challenging, due to the complications of altered rates of
protein metabolism and presence of ascites and edema. The
European Society of Clinical Nutrition and Metabolism
(ESPEN) 2006 guideline recommends the use of the subjective
global assessment (SGA), anthropometry analysis, or the hand-
Up to RDA levelsa
Up to RDA levelsa
Up to RDA levelsa
Restricted to 2 g per d
February 2012
Nutrition Recommendations
Current nutritional recommendations aim to provide
patients with cirrhosis with sufficient energy intake for daily
activities, the increased energy requirements associated with
liver disease, to prevent further protein catabolism for energy,
and to meet nutritional requirements, based on recommended
daily intake. The recommendations proposed in the literature
reflect the higher nutritional needs of patients with advanced
liver disease, who have impaired nutrient absorption, and altered micro- and macronutrient metabolism (Table 1). These
are the basic recommendations for patients changes might be
necessary based on trends in body composition, deficiencies
detected in serologic analyses, and further deterioration of liver
function.
Energy requirements determined for patients are based on
the severity of cirrhosis and the presence of ascites, hypermetabolism, or malnutrition.56 It is important to continuously
monitor weight trends and maintain nutritional status. The
energy recommendation, based on the American Society of
Parenteral and Enteral Nutrition (ASPEN) and ESPEN guidelines, ranges from 25 to 40 kcal/kg per day.51,56 The ASPEN
guideline recommends 25 to 35 kcal/kg per day for patients
without encephalopathy and 35 kcal/kg per day in those with
acute encephalopathy. The 2006 ESPEN guidelines recommend
a much higher energy intake, at 35 to 40 kcal/kg per day for all
patients with stable cirrhosis.51 The ESPEN recommendation
appears to focus on prevention and treatment, due to the
prevalence of malnutrition among cirrhotic patients; the ASPEN guideline also recommends 30 to 40 kcal/kg per day for
stable and malnourished patients.51,56
Energy recommendations are created based on patients dry
weight or, in the presence of ascites, their determined ideal body
weight. The ESPEN guideline recommends use of oral supplement or overnight enteral feeds if patients cannot maintain
adequate intake from food.51
Carbohydrate restriction is not recommended for patients
with cirrhosis despite the high prevalence of insulin resistance
and diabetes in this population.51 With impaired glycogen synthesis and limited glycogen stores in the liver, regular intake of
carbohydrates can help prevent hypoglycemia. Patients are advised to have frequent meals and snacks to reduce the risk of
hypoglycemia, which might subsequently improve oral intake
among patients with poor appetites.56,57 Some studies investigated the use of low glycemic and high-fiber carbohydrate
sources to manage hyperinsulinemia and hyperglycemia; these
were either small or case studies, so their findings cannot be
generalized to all cirrhotic patients.58 60 It has been recommended that carbohydrates account for 45% 65% of caloric
intake, based on the dietary reference intake.61
Historically, protein restriction was recommended in patients with liver disease. The practice originated from the 1970s
and 1980s, when uncontrolled observational studies reported
improvements in hepatic encephalopathy following protein restriction.62 Studies have shown that high-protein diets are not
only well-tolerated in patients with cirrhosis and/or moderate
hepatic encephalopathy, but can also improve their prognosis
and mental status.63 Conversely, protein restriction can lead to
increased protein catabolism, which worsens hepatic encephalopathy, because of the release of ammonia, a by-product of
catabolism. A randomized study showed that patients with
protein intake of 0.5 g/kg per day had an increase in muscle
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breakdown compared with patients with 1.2 g/kg per day protein intake.63
The current protein recommendation for patients with cirrhosis is 1.0 to 1.5 g/kg per day.51,56 This amount is higher than
the 0.8 g/kg per day recommended for healthy individuals,
because of increases in gluconeogenesis, muscle catabolism, and
decreased absorption as in cirrhotic patients. Patients with
acute encephalopathy are placed on temporary protein restriction (0.6 0.8 g/kg per day) until the cause of encephalopathy is
diagnosed and eliminated; then normal protein intake can be
resumed.56
Although several mechanisms appear to contribute to fat
malabsorption, there are no guidelines to support the use of
medium chain triglycerides for patients with cirrhosis. However, if patients appear to have overt fat malabsorption, based
on an abnormal, 72-hour fecal fat test result following a challenge with 100 g fat, it is reasonable to consider this approach.
For patients with advanced liver disease, diet supplementation with fat-soluble vitamins (A, D, E, and K), zinc, and
selenium are recommended; deficiencies in these nutrients are
frequently observed in patients with compensated liver disease.49,56 The recommended intake levels of fat-soluble vitamins
are substantially higher for patients with chronic cholestasis;
when these patients are suspected of having deficiencies
in fat-soluble vitamins, serum levels of vitamin A and 25hydroxyvitamin D [25(OH)D] should be checked, at baseline
and then annually.47,64 For patients with a history of alcohol
abuse, administration of folic acid and thiamin is also advised.56
Because of the increased risks of micronutrient deficiencies
among most patients with advanced liver disease, they should
take a multivitamin routinely.
Patients with edema and ascites are usually placed on
sodium-restricted diets (2 g per day).65 Hospitalized patients with refractory or diuretic-resistant ascites might benefit temporarily from more stringent restrictions in sodium.
It is generally not recommended to discharge patients on
severe sodium restriction dietstheir poor palatability usually leads to poor compliance.66
Probiotics
Patients with cirrhosis have disruptions in the composition of the gastrointestinal microflora, due to medical therapies and abnormal intestinal motility;67 25% have small bowel
bacterial overgrowth, which can promote intestinal wall permeability that results in bacteria translocation, secondary infections, and fat malabsorption with associated consequences.67
Changes in microflora observed in patients with gastrointestinal bacterial overgrowth have been associated with minimal
hepatic encephalopathy (MHE).67 69 MHE is the mildest form
of hepatic encephalopathy, in which patients do not necessarily
have recognizable symptoms but can exhibit mild cognitive and
psychomotor deficits that impact health-related quality of life.
MHE can be treated with lactulose and antibiotics, but use of
these agents is limited by the development of resistant strains of
bacteria and low levels of patient adherence, because of side
effects such as abdominal pain, flatulence, bloating, and diarrhea.68,70
Probiotics are being investigated for their ability to restore
intestinal integrity. They could improve or reverse MHE by
lowering intestinal levels of ammonia and decreasing pH, which
would inhibit growth of pathogenic bacteria and decrease in-
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CHEUNG ET AL
Nocturnal Supplements
Nocturnal oral supplements have been investigated as a
method to reduce gluconeogenesis and protein catabolism. A
12-month randomized control trial followed 108 patients who
received either daytime or bedtime oral nutritional supplementation with 700 calories.80 The study reported a significant
increase in total body protein stores over 3-, 6-, and 12-month
periods in the group given bedtime supplementation, which the
authors attributed to the decreased length of the overnight fast
and associated progression of nocturnal gluconeogenesis.80 The
difference between the 2 groups was equivalent to a gain of 2 kg
of lean muscle tissue, sustained over 12 months.80 Comparatively, there were no significant changes in total body protein
stores over the 12-month period in the group that received
daytime supplements. Improvements in protein stores might be
dependent on the type of nutrients provided, as opposed to the
timing of supplementation.57 For example, a BCAA-rich snack
significantly improved serum levels of albumin, nitrogen balance, and respiratory quotients, compared with the control
group, which was given carbohydrate for 3 months.57 These 2
studies indicate that bedtime supplementation can shorten the
length of overnight fasts and improve protein stores.
February 2012
clear second choice to enteral nutrition.82 Recommended nutrient intake includes provision of carbohydrate to cover 50%
60% of nonprotein energy, with lipid provision to cover 40%
50% of nonprotein energy requirements. Amino acid provision
should amount to 1.2 g/kg per day in patients with compensated cirrhosis and to a dose of 1.5 g/kg per day in those with
decompensated disease.
Conclusions
Many different factors contribute to malnutrition in
patients with chronic liver disease. Impaired hepatocyte functions disrupt the nutrient balance and metabolism, which (in
addition to ascites, protein catabolism, and nutrient deficiencies) can lead to hepatic encephalopathy. Studies have shown
that early detection and treatment of malnutrition is imperative
to improve patient outcomes. In addition to current recommendations for macro- and micronutrient supplementation, the
therapeutic uses of nutrients such as BCAA and probiotics
continue to be investigated.
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Reprint requests
Address requests for reprints to: Maitreyi Raman, MD, MSc, 6D26
TRW Building, 3280 Hospital Drive, Calgary, Alberta T2N 4N1, Canada.
e-mail: mkothand@ucalgary.ca; fax: (403) 592-5090.
Conicts of interest
The authors disclose no conicts.