N u t r i t i o n in C i r r h o s i s a n d C h ro n i c L i v e r Di s e a s e Wassem Juakiem, MDa, Dawn M. Torres, Stephen A. Harrison, MDc,*
MD
b
,
KEYWORDS Cirrhosis Chronic liver disease Nutrition Assessment Management KEY POINTS Malnutrition is common in patients with cirrhosis and increases with disease severity. Deficiencies in vitamins and trace minerals such as vitamins A, D, B12, folate, thiamine, and pyridoxine are common. Bacterial overgrowth is common in patients with cirrhosis and can result in increased bacterial translocation leading to infection and fat malabsorption. The European Society of Clinical Nutrition and Metabolism 2006 guidelines recommend the use of subjective global assessment, anthropometric parameters, or hand grip strength to evaluate nutritional status and detect the presence of malnutrition in patients with cirrhosis.
INTRODUCTION
Chronic liver disease was reported as the ninth leading cause of death in the United States between 1980 and 19891; recent evidence indicates that liver-related mortality has been consistently underestimated in the last 2 decades.2 This has traditionally been associated with viral and alcoholic liver diseases, but the obesity epidemic of the last 2 decades has led to an increase in the incidence of nonalcoholic fatty liver disease (NAFLD), and specifically its subtype nonalcoholic steatohepatitis (NASH), with its adherent risk for progression to cirrhosis. This creates an interesting dichotomy in the discussion of nutrition and chronic liver disease. NAFLD is associated Disclaimer: The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of San Antonio Military Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army, Department of Defense or the US Government. a Department of Medicine, San Antonio Military Medical Center, 3851 Roger Brooke Dr, #3600 Fort Sam Houston, San Antonio, TX 78234, USA; b Division of Gastroenterology, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA; c Division of Gastroenterology and Hepatology, Department of Medicine, San Antonio Military Medical Center, 3851 Roger Brooke Dr, #3600 Fort Sam Houston, San Antonio, TX 78234, USA * Corresponding author. E-mail address: [email protected] Clin Liver Dis 18 (2014) 179–190 http://dx.doi.org/10.1016/j.cld.2013.09.004 1089-3261/14/$ – see front matter Published by Elsevier Inc.
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with excessive caloric intake, metabolic syndrome, and insulin resistance. On the other hand, cirrhosis due to excessive alcohol consumption is typically a catabolic state, often with protein calorie and other nutrient malnutrition.3 The relationship between nutritional status and chronic liver disease is complicated; protein, carbohydrate and lipid metabolism are all affected by the liver. End-stage liver disease (ESLD) and its complications affect energy synthesis and metabolism, which in turn influence nutritional status. Poor nutritional status is linked to multiple medical and surgical complications and affects the outcome of chronic liver disease. Adequate and optimal nutrition regimens are now believed to be important, if not essential, to optimize outcomes including reductions in morbidity and mortality associated with ESLD. This review provides an overview of the common nutritional deficiencies associated with non-NAFLD cirrhosis as well as the nutrition supplementation and dietary strategies investigated to date to address this unmet need in cirrhosis management. PREVALENCE
Malnutrition is common in patients with cirrhosis, particularly those with advanced disease; the malnutrition rate in patients with cirrhosis is 50% to 90%. In a study of 300 patients by Carvalho and Parise,4 75% of those with advanced liver disease displayed some degree of malnutrition. The same study also showed that malnutrition incidence increased with Child-Pugh class. Patients with Child-Pugh A had a 46% rate of malnutrition compared with 84% of patients with Child-Pugh B, and 95% with Child-Pugh C. The prevalence of malnutrition among patients with cirrhosis is particularly concerning because of its association with mortality and inherent complications. In multiple studies, protein calorie malnutrition (PCM) has been described in 50% to 100% of patients with decompensated cirrhosis and at least 20% with compensated cirrhosis.5–8 PCM is associated with an increased number of complications including ascites, variceal bleeding, increased surgical morbidity and mortality, reduced survival, and worsening hepatic function.9 This was demonstrated in a large nationwide analysis of hospitalized patients with cirrhosis and portal hypertension; PCM was more frequently associated with ascites (65% vs 48%, P
MD
b
,
KEYWORDS Cirrhosis Chronic liver disease Nutrition Assessment Management KEY POINTS Malnutrition is common in patients with cirrhosis and increases with disease severity. Deficiencies in vitamins and trace minerals such as vitamins A, D, B12, folate, thiamine, and pyridoxine are common. Bacterial overgrowth is common in patients with cirrhosis and can result in increased bacterial translocation leading to infection and fat malabsorption. The European Society of Clinical Nutrition and Metabolism 2006 guidelines recommend the use of subjective global assessment, anthropometric parameters, or hand grip strength to evaluate nutritional status and detect the presence of malnutrition in patients with cirrhosis.
INTRODUCTION
Chronic liver disease was reported as the ninth leading cause of death in the United States between 1980 and 19891; recent evidence indicates that liver-related mortality has been consistently underestimated in the last 2 decades.2 This has traditionally been associated with viral and alcoholic liver diseases, but the obesity epidemic of the last 2 decades has led to an increase in the incidence of nonalcoholic fatty liver disease (NAFLD), and specifically its subtype nonalcoholic steatohepatitis (NASH), with its adherent risk for progression to cirrhosis. This creates an interesting dichotomy in the discussion of nutrition and chronic liver disease. NAFLD is associated Disclaimer: The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of San Antonio Military Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army, Department of Defense or the US Government. a Department of Medicine, San Antonio Military Medical Center, 3851 Roger Brooke Dr, #3600 Fort Sam Houston, San Antonio, TX 78234, USA; b Division of Gastroenterology, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA; c Division of Gastroenterology and Hepatology, Department of Medicine, San Antonio Military Medical Center, 3851 Roger Brooke Dr, #3600 Fort Sam Houston, San Antonio, TX 78234, USA * Corresponding author. E-mail address: [email protected] Clin Liver Dis 18 (2014) 179–190 http://dx.doi.org/10.1016/j.cld.2013.09.004 1089-3261/14/$ – see front matter Published by Elsevier Inc.
liver.theclinics.com
180
Juakiem et al
with excessive caloric intake, metabolic syndrome, and insulin resistance. On the other hand, cirrhosis due to excessive alcohol consumption is typically a catabolic state, often with protein calorie and other nutrient malnutrition.3 The relationship between nutritional status and chronic liver disease is complicated; protein, carbohydrate and lipid metabolism are all affected by the liver. End-stage liver disease (ESLD) and its complications affect energy synthesis and metabolism, which in turn influence nutritional status. Poor nutritional status is linked to multiple medical and surgical complications and affects the outcome of chronic liver disease. Adequate and optimal nutrition regimens are now believed to be important, if not essential, to optimize outcomes including reductions in morbidity and mortality associated with ESLD. This review provides an overview of the common nutritional deficiencies associated with non-NAFLD cirrhosis as well as the nutrition supplementation and dietary strategies investigated to date to address this unmet need in cirrhosis management. PREVALENCE
Malnutrition is common in patients with cirrhosis, particularly those with advanced disease; the malnutrition rate in patients with cirrhosis is 50% to 90%. In a study of 300 patients by Carvalho and Parise,4 75% of those with advanced liver disease displayed some degree of malnutrition. The same study also showed that malnutrition incidence increased with Child-Pugh class. Patients with Child-Pugh A had a 46% rate of malnutrition compared with 84% of patients with Child-Pugh B, and 95% with Child-Pugh C. The prevalence of malnutrition among patients with cirrhosis is particularly concerning because of its association with mortality and inherent complications. In multiple studies, protein calorie malnutrition (PCM) has been described in 50% to 100% of patients with decompensated cirrhosis and at least 20% with compensated cirrhosis.5–8 PCM is associated with an increased number of complications including ascites, variceal bleeding, increased surgical morbidity and mortality, reduced survival, and worsening hepatic function.9 This was demonstrated in a large nationwide analysis of hospitalized patients with cirrhosis and portal hypertension; PCM was more frequently associated with ascites (65% vs 48%, P
