Nutrition in Pediatric Chronic Liver Disease

Normatov, Inessa; Kaplan, Shiran; Azzam, Ruba

doi:10.3928/19382359-20181022-03

Cited by 9 publications

(9 citation statements)

References 21 publications

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“…Excellent long-term patient survival rates after LT have broadened the indications for pediatric LT to include etiologies such as metabolic liver diseases and liver malignancies, although infants and children with ESLD caused by BA and other cholestatic conditions still constitute the majority of waiting lists worldwide. (39) Malnutrition is a known predictor of poor outcomes in children undergoing LT. (40,41) However, the currently available armamentarium of clinical tools to accurately ascertain a poor nutritional state in children is limited by confounders such as ascites and organomegaly. Sarcopenia has been well studied in adults with cirrhosis, with sobering adverse outcomes of increased waitlist mortality and increased postoperative complications.…”

Section: Discussionmentioning

confidence: 99%

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Sarcopenia in Children With End‐Stage Liver Disease on the Transplant Waiting List

et al. 2021

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Sarcopenia predicts morbidity and mortality in adults with end-stage liver disease (ESLD) and is determined by total psoas muscle area (tPMA) measurement from computed tomography (CT) imaging. Recently developed pediatric age-and sex-specific tPMA growth curves provide the opportunity to ascertain the prevalence and impact of sarcopenia in children awaiting liver transplantation (LT). We performed a retrospective single-center study to evaluate sarcopenia in children with ESLD between 1 and 16 years of age with a clinically indicated abdominal CT less than 3 months before first isolated LT. Sarcopenia was defined as a tPMA z score less than −2 measured at the intervertebral L4-5 level. Patient demographic, biochemical, and outcome data were recorded. tPMA was compared to other measures of nutritional and growth status using univariate and multivariate logistic analyses. Outcome measures included 1-year morbidity events and mortality after LT. CT images from 25 (64% female) children with a median age of 5.50 (interquartile range [IQR], 3.75, 11.33) years were reviewed. Of the 25 children with ESLD, 10 (40%) had a tPMA z score less than −2. Sarcopenia was associated with lower z scores for weight (odds ratio [OR], 0.38; P = 0.02) and height (OR, 0.32; P = 0.03) and nutritional support before LT (OR, 12.93; P = 0.01). Patients with sarcopenia had a longer duration of pediatric intensive care unit (PICU) stay (3.50 [IQR, 3.00, 6.00] vs. 2.00 [IQR, 2.00, 3.50] days; P = 0.03). Sarcopenia was prevalent in 40% of children with ESLD who underwent clinically indicated CT while awaiting LT, and lower tPMA z score was associated with anthropometrics and need for nutritional support before LT. Post-LT PICU duration was increased in children with sarcopenia, reflecting adverse outcomes associated with muscle loss. Further studies are needed to elucidate the underlying mechanisms of sarcopenia in children with ESLD. Sarcopenia, defined as a decrease in skeletal muscle mass and function, is a frequent finding in adults with cirrhosis. (1-3) In a recent consensus statement by the North American Working Group on Sarcopenia in Liver Transplantation, computed tomography (CT) assessment of total psoas muscle area (tPMA) was recommended as the gold-standard technique to assess sarcopenia in patients with cirrhosis. (4) Unaffected by ascites, tPMA is linearly related to whole body mass, providing an estimation of overall lean muscle mass in patients with end-stage liver disease (ESLD).

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Section: Discussionmentioning

confidence: 99%

“…lists worldwide. (39) Malnutrition is a known predictor of poor outcomes in children undergoing LT. (40,41) However, the currently available armamentarium of clinical tools to accurately ascertain a poor nutritional state in children is limited by confounders such as ascites and organomegaly.…”

Section: Accepted Articlementioning

confidence: 99%

Sarcopenia in Children With End‐Stage Liver Disease on the Transplant Waiting List

et al. 2021

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“…Malnutrition itself is a serious risk factor for short and long-term morbidity and mortality in children, undergoing LT. [31][32][33][34][35][36] Malnutrition predisposes a patient to complications such as compromised respiratory function, delayed wound healing, longer dependency on mechanical ventilation, increased rates of septic complications, use of antibiotics, blood products usage, length of hospital and ICU stay, graft loss delayed physical rehabilitation and substantially higher cost of the transplant. [31][32][33][34][35][36] Additionally, 80% of those who needed tracheostomy had abnormalities in left ventricular geometry detected on echocardiography prior to LT, which is shown to correlate with serious adverse events outcomes post-LT including acute graft failure, severe hemorrhage and need for prolonged renal replacement therapy. 15 Along with these coexisting chronic comor- Children with tracheostomy are overall at higher risk for mortality.…”

Section: Discussionmentioning

confidence: 99%

“…Three quarters of those who needed tracheostomy exhibited severe stunting at the time of LT. Stunting is the end result of chronic or recurrent undernutrition and is one of the three key metrics used by the WHO to diagnose malnutrition. Malnutrition itself is a serious risk factor for short and long‐term morbidity and mortality in children, undergoing LT 31‐36 . Malnutrition predisposes a patient to complications such as compromised respiratory function, delayed wound healing, longer dependency on mechanical ventilation, increased rates of septic complications, use of antibiotics, blood products usage, length of hospital and ICU stay, graft loss delayed physical rehabilitation and substantially higher cost of the transplant 31‐36 .…”

Section: Discussionmentioning

confidence: 99%

The use of tracheostomy to support critically ill children receiving orthotopic liver transplantation: a single‐center experience

Mian

Kennedy

Fogarty

et al. 2021

Pediatric Transplantation

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Background: Children with end-stage liver disease and multi-organ failure, previously considered as poor surgical candidates, can now benefit from liver transplantation (LT). They often need prolonged mechanical ventilation (MV) post-LT and may need tracheostomy to advance care. Data on tracheostomy after pediatric LT are lacking. Method:Retrospective chart review of children who required tracheostomy in the peri-LT period in a large, freestanding quaternary children's hospital from 2014 to 2019.Results: Out of 205 total orthotopic LTs performed in 200 children, 18 (9%) required tracheostomy in the peri-transplant period: 4 (2%) pre-LT and 14 (7%) post-LT. Among those 14 needing tracheostomy post-LT, median age was 9 months [IQR = 7, 14] at LT and 10 months [9,17] at tracheostomy. Nine (64%) were infants and 12 (85%) were cirrhotic at the time of LT. Seven (50%) were intubated before LT. Median MV days prior to LT was 23 [7,36]. Eight (57%) patients received perioperative continuous renal replacement therapy (CRRT). The median MV days from LT to tracheostomy was 46 [33, 56]; total MV days from initial intubation to tracheostomy was 57 [37, 66]. Four (28%) children died, of which 3 (21%) died within 1 year of transplant. Total ICU and hospital length of stay were 92 days [I72, 126] and 177 days [115, 212] respectively. Among survivors, 3/10 (30%) required MV at home and 8/10 (80%) were successfully decannulated at 400 median days [283, 584]. Conclusion:Tracheostomy though rare after LT remains a feasible option to support and rehabilitate critically ill children who need prolonged MV in the peri-LT period.

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“…First, the principal cause of malnutrition is reduced oral intake, and this can be due to anorexia, early satiety, nausea and cognitive impairment in the setting of hepatic encephalopathy. Patients with liver cirrhosis often have altered taste and smell, which can cause anorexia due to changes in the oral flora, use of antibiotics, dry mouth, zinc or magnesium deficiency[ 6 ]. Additionally, imbalances between orexigenic and anorexigenic hormones and chronic elevations in cytokines like tumor necrosis factor (TNF)-α can also trigger anorexia[ 7 , 8 ].…”

Section: Pathogenesismentioning

confidence: 99%

Nutritional assessment in patients with liver cirrhosis

Ali¹,

Sneineh²,

Hasweh³

2022

World J Hepatol

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Malnutrition is a liver cirrhosis complication affecting more than 20%-50% of patients. Although the term can refer to either nutrient deficiency or excess, it usually relates to undernutrition in cirrhosis settings. Frailty is defined as limited physical function due to muscle weakness, whereas sarcopenia is defined as muscle mass loss and an advanced malnutrition stage. The pathogenesis of malnutrition in liver cirrhosis is multifactorial, including decreased oral intake, maldigestion/malabsorption, physical inactivity, hyperammonemia, hypermetabolism, altered macronutrient metabolism and gut microbiome dysbiosis. Patients with chronic liver disease with a Body Mass Index of < 18.5 kg/m 2 and/or decompensated cirrhosis or Child-Pugh class C are at the highest risk of malnutrition. For patients at risk of malnutrition, a detailed nutritional assessment is required, typically including a history and physical examination, laboratory testing, global assessment tools and body composition testing. The latter can be done using anthropometry, cross-sectional imaging including computed tomography or magnetic resonance, bioelectrical impedance analysis and dual-energy X-ray absorptiometry. A multidisciplinary team should screen for and treat malnutrition in patients with cirrhosis. Malnutrition and sarcopenia are associated with an increased risk of complications and a poor prognosis in patients with liver cirrhosis; thus, it is critical to diagnose these conditions early and initiate the appropriate nutritional therapy. In this review, we describe the prevalence and pathogenesis of malnutrition in liver cirrhosis patients and discuss the best diagnostic approach to nutritional assessment for them.

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Nutrition in Pediatric Chronic Liver Disease

Cited by 9 publications

References 21 publications

Sarcopenia in Children With End‐Stage Liver Disease on the Transplant Waiting List

Sarcopenia in Children With End‐Stage Liver Disease on the Transplant Waiting List

The use of tracheostomy to support critically ill children receiving orthotopic liver transplantation: a single‐center experience

Nutritional assessment in patients with liver cirrhosis

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