Liver cirrhosis is an increasing public health threat worldwide. Malnutrition is a serious complication of cirrhosis and is associated with worse outcomes. With this review, we aim to describe the prevalence of malnutrition, pathophysiological mechanisms, diagnostic tools and therapeutic targets to treat malnutrition. Malnutrition is frequently underdiagnosed and occurs—depending on the screening methods used and patient populations studied—in 5–92% of patients. Decreased energy and protein intake, inflammation, malabsorption, altered nutrient metabolism, hypermetabolism, hormonal disturbances and gut microbiome dysbiosis can contribute to malnutrition. The stepwise diagnostic approach includes a rapid prescreen, the use of a specific screening tool, such as the Royal Free Hospital Nutritional Prioritizing Tool and a nutritional assessment by dieticians. General dietary measures—especially the timing of meals—oral nutritional supplements, micronutrient supplementation and the role of amino acids are discussed. In summary malnutrition in cirrhosis is common and needs more attention by health care professionals involved in the care of patients with cirrhosis. Screening and assessment for malnutrition should be carried out regularly in cirrhotic patients, ideally by a multidisciplinary team. Further research is needed to better clarify pathogenic mechanisms such as the role of the gut-liver-axis and to develop targeted therapeutic strategies.

The European Working group on Sarcopenia in Older People recently updated the diagnostic criteria for sarcopenia. It is yet unclear how these modified criteria influence the rate of diagnosis in high risk populations, such as liver cirrhosis. We therefore assessed if the new diagnostic criteria for sarcopenia impacts on sarcopenia prevalence in liver cirrhosis. Within two years 114 cirrhotic patients were prospectively enrolled in the study. Sarcopenia was determined by muscle strength (handgrip strength), muscle mass (lumbal muscle index) and muscle performance (gait speed). Using the 2019 definition, the rate of pre-sarcopenia was significantly lower (30.7% versus 3.5%) due to the different starting points (2010 muscle mass, 2019 muscle strength) and cut-off values (muscle strength). The change in diagnostic criteria for sarcopenia drastically influences the rate of pre-sarcopenia diagnosis in cirrhotics. To evaluate, which diagnostic criteria should be chosen to diagnose sarcopenia in liver cirrhosis patients, prospective studies are needed.

Malnutrition in liver cirrhosis is frequently underestimated. To determine if a patient is at risk of malnutrition, several screening tools have been established. However, most of them are not validated for patients with liver cirrhosis. Therefore, we compared the RFH-NPT (Royal Free Hospital Nutritional Prioritizing Tool) as the validated gold standard for malnutrition screening in cirrhosis patients with GMS (Graz Malnutrition Screening), NRS-2002 (Nutritional Risk Screening) and MNA-SF (Mini Nutritional Assessment-Short Form). Based on common validity criteria for screening tools, only the MNA-SF showed fair correlation (12/15 points) with the RFH-NPT, whereas NRS-2002 and GMS performed worse (6/15 points). Taken together, our results suggest that NRS-2002 and GMS are not suitable for screening of malnutrition in cirrhosis patients. A cirrhosis-specific screening tool like RFH-NPT should be used to assess malnutrition and to identify those at risk of malnutrition.

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The European Working group on Sarcopenia in Older People recently updated the diagnostic criteria for sarcopenia. It is yet unclear how these modified criteria influence the rate of diagnosis in high risk populations, such as liver cirrhosis. We therefore assessed if the new diagnostic criteria for sarcopenia impacts on sarcopenia prevalence in liver cirrhosis. Within two years 114 cirrhotic patients were prospectively enrolled in the study. Sarcopenia was determined by muscle strength (handgrip strength), muscle mass (lumbal muscle index) and muscle performance (gait speed). Using the 2019 definition, the rate of pre-sarcopenia was significantly lower (30.7% versus 3.5%) due to the different starting points (2010 muscle mass, 2019 muscle strength) and cut-off values (muscle strength). The change in diagnostic criteria for sarcopenia drastically influences the rate of pre-sarcopenia diagnosis in cirrhotics. To evaluate, which diagnostic criteria should be chosen to diagnose sarcopenia in liver cirrhosis patients, prospective studies are needed.

In light of the increasing life expectancy of Europe's population and the rising significance of active and healthy ageing relating thereto, an integrated approach of nutritional care within primary health care is gaining importance. The aim of the review was to summarize evidence on the effectiveness of nutritional interventions in primary health care. The scoping review is based upon a comprehensive literature search of relevant literature published between January 2010 and August 2021 in PubMed, CINAHL, Cochrane Database of Systematic Reviews, Embase and Medline databases. Overall, 15 studies were included for evidence synthesis and interventions were basically clustered according to their type, into 1) eHealth and tele-medical interventions; 2) targeted single interventions; and 3) comprehensive, multi-faceted interventions. The review presents diverging evidence regarding the efficacy and effectiveness of interventions for nutritional care in primary health care, however, demonstrates encouraging outcomes. eHealth and tele-medical interventions partly show a careful positive tendency. Likewise, manifold single interventions on patient level present significant improvements in patient health outcomes. Multifaceted and comprehensive interventions found in the literature also partly demonstrate significant changes in intervention groups. Primary health care represents a critical setting for the care of older citizens and patients with complex health needs. This scoping review provides an overview of current nutrition care practices in primary health care and results reinforce the need to strengthen implementation of multi-faceted interventions carried out by the inter-disciplinary primary care team for advanced nutritional care.

L-ornithine L-aspartate (LOLA) is administered as a therapeutic and/or preventive strategy against hepatic encephalopathy either intravenously or orally in patients with liver cirrhosis. Here, we analyzed how LOLA influences the microbiome and metabolome of patients with liver cirrhosis. We retrospectively analyzed the stool microbiome, stool, urine and serum metabolome as well as markers for gut permeability, inflammation and muscle metabolism of 15 cirrhosis patients treated orally with LOLA for at least one month and 15 propensity-score-matched cirrhosis patients without LOLA. Results were validated by comparing the LOLA-treated patients to a second set of controls. Patients with and without LOLA were comparable in age, sex, etiology and severity of cirrhosis as well as PPI and laxative use. In the microbiome, Flavonifractor and Oscillospira were more abundant in patients treated with LOLA compared to the control group, while alpha and beta diversity were comparable between groups. Differences in stool and serum metabolomes reflected the pathophysiology of hepatic encephalopathy and confirmed LOLA intake. In the urine metabolome, ethanol to acetic acid ratio was lower in patients treated with LOLA compared to controls. LOLA-treated patients also showed lower serum levels of insulin-like growth factor (IGF) 1 than patients without LOLA. No differences in gut permeability or inflammation markers were found. A higher abundance of Flavonifractor and Oscillospira in LOLA-treated patients could indicate LOLA as a potential microbiome modulating strategy in patients with liver disease. The lower levels of IGF1 in patients treated with LOLA suggest a possible link between the pathophysiology of hepatic encephalopathy and muscle health.

ZusammenfassungDiabetesschulung und Selbstmanagement nehmen eine zentrale Rolle in der Diabetesbetreuung ein. Das dabei angestrebte Patient:innen-Empowerment zielt auf die aktive Beeinflussung des Diabetesverlaufs durch Selbstkontrolle und Therapieanpassung sowie die Befähigung der Betroffenen, den Diabetes in ihren Alltag zu integrieren und an ihre Lebensumstände entsprechend anzupassen. Eine Diabetesschulung ist allen Personen mit Diabetes zugänglich zu machen. Um ein strukturiertes und validiertes Schulungsprogramm anbieten zu können, sind adäquate personelle, räumliche, organisatorische und finanzielle Voraussetzungen nötig. Neben dem Zuwachs an Wissen über die Erkrankung konnte gezeigt werden, dass eine strukturierte Diabetesschulung ergebnisorientiert Parameter wie Blutzucker, HbA1c, Blutfette, Blutdruck und Körpergewicht positiv beeinflussen kann. Neuere Schulungsmodelle betonen neben der Ernährung die körperliche Bewegung als wichtigen Bestandteil der Lebensstil-Therapie und bedienen sich interaktiver Methoden, um die persönliche Verantwortung herauszuarbeiten. Spezifische Situationen (z. B. verminderte Hypoglykämie-Erkennung, Krankheit, Reisen), das Auftreten diabetischer Folgeerkrankungen und der Einsatz technischer Geräte wie Glukosesensor-Systeme und Insulinpumpen bedürfen zusätzlicher Schulungsmaßnahmen unterstützt durch adäquate elektronische Hilfsmittel (Diabetes-Apps, Diabetes-Web-Portale). Neue Erkenntnisse belegen den Nutzen telemedizinischer oder internetbasierter Dienste für die Diabetesprävention und das Diabetesmanagement.