Liver cirrhosis is a diffuse chronic liver disease affecting the entire liver. The fibrosis accumulation and distribution in the liver are known to be heterogeneous. „Localized” or „focal” cirrhosis is only anecdotically reported. Acute hepatitis E virus (HEV) infection is uncommon in western countries, especially in temperate climate areas and is very often missed or underdiagnosed. However, it may be responsible of up to 15% of acute-on-chronic liver failure cases. We present the case of a 35-year-old patient with a very uncommon association of Budd-Chiari syndrome secondary to hepatocellular carcinoma (HCC) developed on a non-cirrhotic right liver lobe and secondary biliary cirrhosis of the left liver lobe, that further complicated with acute HEV infection leading to acute-on-chronic liver failure and death.Abbreviations: Alb: Albumin; AFP: alpha feto-protein; ALP: alkaline phosphatase; ALT: alanine aminotransferase; AST: aspartate aminotransferase; BCS: Budd-Chiari syndrome; CK7: cytokeratin 7; CMV: cytomegalovirus; EBV: Epstein-Barr virus; GGT: gamma glutamyl transpeptidase; HBV: hepatitis B virus; HCV: hepatitis C virus; HEV: hepatitis E virus; HSV: hepes simplex virus; HCC: hepatocellular carcinoma; IVC: inferior vena cava; MELD: model for end-stage liver disease; (MD)CT: (multi-detector) computer tomography; PT: prothrombin time; TB: total bilirubin.
BACKGROUND
Malnutrition is frequently encountered in patients with cirrhosis and appears to significantly impact their prognosis. While evaluating the burden of malnutrition in cirrhosis is gathering momentum, as suggested by multiple recently published reports, there is still a persistent scarcity of solid data in the field, especially with regards to the role of nutritional interventions.
AIM
To assess the prevalence of malnutrition in patients with advanced cirrhosis and to evaluate its impact on survival.
METHODS
One hundred and one consecutive patients with advanced cirrhosis were screened for malnutrition using the Subjective Global Assessment (SGA) criteria and the mid-arm circumference (MAC). Malnutrition was defined as SGA class B and C and MAC < 10
th
percentile. All patients were interviewed regarding their food intake using an adapted questionnaire. Subsequently, total energy intake was calculated and further subdivided in main nutrients. The data were then compared to the available recommendations at the time of analysis to assess adherence.
RESULTS
54/79 patients (68.4%) in the decompensated group had malnutrition, while only 3/22 patients (13.6%) were malnourished in the compensated group. After a median follow-up time of 27 mo (0-53), the overall mortality was 70%. Survival was significantly lower among patients with malnutrition. The mortality rates were 50% at 1 year and 63% at 2 years for the patients with malnutrition, compared to 21% at 1 year and 30% at 2 years for patients without malnutrition (
P
= 0.01). On multivariate analysis, the factors independently associated with mortality were age, creatinine level and adherence to the protein intake recommendations. The mortality was lower in patients with the appropriate protein intake: 8% at 1 year and 28% at 2 years in the adherent group, compared to 47% at 1 year and 56% at 2 years in the non-adherent group.
CONCLUSION
The prevalence of malnutrition is high among patients with advanced cirrhosis and might be related in part to a low adherence to nutritional recommendations, especially with regards to protein intake.
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