Systematic review with meta‐analysis: Nutritional screening and assessment tools in cirrhosis

Abstract

Background & Aims Disease‐related malnutrition is common in cirrhosis. Multiple studies have evaluated nutritional screening tools (NSTs, rapid bedside tests targeting who needs assessment) and nutritional assessment tools (NATs, used in diagnosing malnutrition) as predictors of clinical outcome in this population. We performed a systematic review and meta‐analysis of this literature with the aim of summarising the varying definitions of malnutrition across studies, the available evidence for NSTs and the ability of NSTs and NATs to predict clinical outcomes in cirrhosis. Methods The primary outcome measures were pre‐ and post‐transplant mortality with a range of secondary outcomes. Inclusion: cirrhosis over age 16. Exclusion: >25% with hepatocellular carcinoma, primarily laboratory test‐based NATs or lack of screening, assessment or outcome criteria. Results Eight thousand eight hundred fifty patients were included across 47 studies. Only 3 studies assessed NSTs. Thirty‐two definitions for malnutrition were utilised across studies. NATs predicted pre‐transplant mortality in 69% of cases that were assessed with a risk ratio (RR) of 2.38 (95% CI 1.96‐2.89). NATs were prognostic for post‐transplant mortality only 28% of the times they were assessed, with a RR of 3.04 (95% CI 1.51‐6.12). Conclusions The cirrhosis literature includes limited data on nutrition screening and multiple definitions for what constitutes malnutrition using NATs. Despite this discordance, it is clear that malnutrition is a valuable predictor of pre‐transplant mortality almost regardless of how it is defined. We require clinical and research consensus around the definition of malnutrition and the accepted processes and cut‐points for nutrition screening and assessment in cirrhosis.

Molecular Mechanism Contributing to Malnutrition and Sarcopenia in Patients with Liver Cirrhosis

“…DRM is a robust and independent predictor of adverse clinical outcomes including infections, hepatic encephalopathy, hospitalization and mortality [ 21 , 26 ]. In many patient populations, DRM and sarcopenia are present in parallel, and often manifest clinically in a malnutrition-sarcopenia syndrome (MSS) [ 27 ].…”

A narrative review of malnutrition in chronic liver disease

“…To date, about 32 different definitions of malnutrition were introduced (1). In most papers, the NAT, and the nutrition screening tool (NST) have been confusingly used.…”

“…Prevalence of malnutrition is common in patients with chronic liver diseases. Malnutrition increases mortality and aggravated disease course of liver diseases (1). Therefore, an accurate evaluation of a patient's nutritional status is important for the treatment and management of chronic liver disease.…”

“…Previously, each study used a wide variety of diagnostic tools and different cut off values even when using the same diagnostic tool. Various approaches used comprised of subjective global assessment (SGA), mid arm muscle circumference (MAMC), triceps skinfold thickness (TSF), and handgrip strength (HGS); however, each study used different criteria (1,5). In addition, cut-off values to define malnutrition also varied to a great extent even in some cases where the same evaluation tool was used.…”

Nutrition in Liver Cirrhosis and Transplantation—Current State and Knowledge Gaps

“…For example, the ideal tools for calculating resting energy expenditure are unknown, as predictive equations to calculate energy requirements are inaccurate compared to gold-standard indirect calorimetry, which is not practical in the clinic-based setting. Several nutrition screening tools are available; however, very few of these have been validated against nutrition assessment tools, or relevant clinical outcomes [3]. A busy clinical setting may limit clinicians from engaging in nutrition screening or assessment due to a lack of knowledge about optimal screening tool selection.…”