A practical approach to nutritional screening and assessment in cirrhosis

Abstract

Malnutrition is one of the most common complications of cirrhosis, associated with an increased risk of morbidity and mortality. As a potentially modifiable condition, it is of particular importance to identify malnourished patients so that nutritional therapy can be instituted. Nutrition screening and assessment are infrequently performed in patients with cirrhosis. The reasons for this are multifactorial, including the absence of a validated "rapid" screening tool, multiple definitions of what constitutes malnutrition, and challenges with interpreting body composition and laboratory results in the setting of volume overload and liver dysfunction. This article summarizes the clinically relevant evidence and presents key issues, tools, and clinical options that are applicable to patients with cirrhosis. The definition, etiology, and clinically relevant outcomes associated with malnutrition are reviewed. Rapid nutritional screening is differentiated from more detailed nutritional assessment. Nutritional assessment in special populations, including women and the obese, and the role of inflammation are discussed. Multicenter studies using a common nutritional screening/assessment strategy are the next steps to fast-track adoption and implementation of nutrition-related evaluations into routine clinical practice. (Hepatology 2017;65:1044-1057).

A Comprehensive Review of Bioelectrical Impedance Analysis and Other Methods in the Assessment of Nutritional Status in Patients with Liver Cirrhosis

“…Researchers proved a correlation between malnutrition and mortality in a compensated group of patients, but these data deserve particular attention and further research [12]. Nevertheless, the identification of the best nutritional assessment method still remains a controversial topic, and the gold standard in this area has not been established yet [13, 14]. Several methods are performed to assess nutritional status of cirrhotic patients.…”

The Challenges of Nutritional Assessment in Cirrhosis

“…Therefore, the approach to patient nutritional and metabolic derangements should be based on a combination of practice guidelines, published evidence, and clinical experience [25]. …”

“…Considered as a potentially modifiable condition, protein-calorie malnutrition may be assessed by a comprehensive nutritional evaluation aimed at determining if cirrhotic patients are at risk of malnutrition or at identifying the severity of already existing malnutrition and its changes overtime [25, 26]. The ideal tool for the nutritional assessment should be easy to use by health care professionals, including untrained physicians and nurses, and it should have reasonable sensitivity, specificity, and reproducibility [27].…”

“…Body weight, waist and arm circumference, triceps skinfold thickness, and BMI often provide an inaccurate classification of malnutrition as they are all affected by the fluid retention that often occurs in patients with cirrhosis [25]. Therefore, it appears clinically relevant to have a predictable estimation of the dry weight in patients presenting with fluid retention.…”

“…To date, none of these appetite assessment tools have been validated in the setting of cirrhosis [25]. …”