Nutritional assessment in chronic liver disease

Nutritional assessment in chronic liver disease
Shaimaa ElKholy, M.D Cairo University, Egypt Shaimaa Elkholy, M.D. Cairo University

Shaimaa Elkholy, M.D. Cairo University
Agenda: Introduction. Pathogenesis of malnutrition in CLD. Goals of nutritional assessment. Steps of nutritional assessment. Nutrition guidelines. Summary and recommendations. Shaimaa Elkholy, M.D. Cairo University

Introduction: Protein energy malnutrition (PEM) is a common complication of liver cirrhosis, it has been found to increase morbidity and mortality in these patients. In patients with liver cirrhosis PEM about 65%–90% of decompensated 20% of compensated liver cirrhosis. Shaimaa Elkholy, M.D. Cairo University

Introduction: In liver transplantation PEM has been reported in 100% of patients prior to transplantation. Malnourishment was found to be an independent risk factor for morbidity and mortality in patients following liver transplantation. Shaimaa Elkholy, M.D. Cairo University

Pathogenesis: Multifactorial. Protien, CHO, and lipid metabolism are all affected by liver disease. Contributing factors: Inadequate dietary intake Impaired digestion Impaired Absorption Shaimaa Elkholy, M.D. Cairo University

Impaired digestion Altered metabolism Impaired absorption In adequate intake Shaimaa Elkholy, M.D. Cairo University

Decreased intake *Anorexia *Nausea *Encephalopathy *Gastritis *Ascites *A sodium restricted diet *Concurrent alcohol consumption Malabsorption and Maldigestion * Bile salt deficiency, * Bacterial overgrowth * Altered intestinal motility * Portal hypertensive changes to the intestine * Increased intestinal permeability * Pancreatic insufficiency Shaimaa Elkholy, M.D. Cairo University

Cirrhosis represents an accelerated state of starvation (hypermetabolism) Abnormal CHO metabolism Insulin resistance Impaired gluconeogenesis Reduced glycogen stores loss of protein ⇩ Synthesis of urea and hepatic proteins. ⇩ Intestinal protein absorption ⇧ Urinary nitrogen excretion Lowe ratio of BCAA/ AAA. lipids are preferentially oxidized for energy Shaimaa Elkholy, M.D. Cairo University

Goals of nutritional assessment
Identify nutritional risk that influences morbidity and mortality and which may be modifiable with targeted nutritional therapy. Determine the macronutrient (energy, protein, water) and micronutrient (electrolytes, minerals, vitamins, trace elements) state of a given individual. Body composition and muscle function analysis add supplemental information. Shaimaa Elkholy, M.D. Cairo University

Nutritional assessment
There is no gold standard rule for the assessment of the nutritional of status in patients with cirrhosis Shaimaa Elkholy, M.D. Cairo University

Steps for nutritional assessment
Patients with compensated cirrhosis are more likely to be similar to a healthy population on clinically or laboratory basis. Nutritional assessment is generally more detailed in patients with decompensated disease Standard nutrition assessment tools have limitations with decompensated liver cirrhosis. Shaimaa Elkholy, M.D. Cairo University

Detailed nutritional assessment in all patients is not required. A Staged approach is suggested beginning with a complete history and physical examination and proceeding with more detailed testing if needed. Shaimaa Elkholy, M.D. Cairo University

History Physical examination Subjective global assessment Laboratory evaluation Anthropometry Miscellaneous tests Shaimaa Elkholy, M.D. Cairo University

1.History B) Dietary intake the 24 hour dietary recall The patient recounts meals and snacks on a typical day (intake of food from each of the food groups plus nutritional supplements) Alcohol intake should also be quantified A) Weight history recent weight loss (two weeks) weight lost over six months Unintentional wt loss of >10 % over six months is considered severe less accurate in patients with decompensated cirrhosis C) Gastrointestinal symptoms Anorexia Nausea Vomiting diarrhea, and steatorrhea Presence > two week with a limitation in nutrient intake are concerning. Shaimaa Elkholy, M.D. Cairo University

D) Liver disease The nature and severity of liver disease: Compensated decompensated liver (Child Pugh score)(MELD) disease. E) Micronutrient deficiency Features suggestive of micronutrient deficiency e.g. Dermatitis (zinc, vitamin A, niacin) Night blindness or photophobia (vitamin A) Burning of the mouth or tongue (vitamin B12 folate) Paresthesias (thiamine, pyridoxine). Shaimaa Elkholy, M.D. Cairo University

2.Physical examination Body mass index (BMI). Oedema as ankle, sacral edema or ascites. Muscle wasting as in quadriceps and deltoids. Loss of subcutaneous fat ( triceps and chest). Micronutrient deficiency e.g. pallor (iron deficiency), hyperkeratosis (vitamin A)…..etc. Shaimaa Elkholy, M.D. Cairo University

3. Subjective global assessment
Simple bedside tool which assesses nutritional status based on features of the history and physical examination. Five components of the SGA : Weight loss. Change in dietary intake. Presence of gastrointestinal symptoms. Functional capacity. Metabolic demand. Shaimaa Elkholy, M.D. Cairo University

History Weight change Overall loss in past 6 months: amount = # ___________ kg; % loss = # ____________________Change in past 2 weeks: ___________________ increase, ___________________ no change, ___________________ decrease. 2. Dietary intake change (relative to normal) ___________No change, ___________Change ________________duration = # ____________________ weeks ________________type: __________ suboptimal liquid diet, _________ full liquid diet __________ hypo caloric liquids, _________ starvation. 3. Gastrointestinal symptoms (that persisted for >2 weeks) __________none, __________nausea, __________vomiting, __________diarrhea, __________anorexia. 4. Functional capacity ___________ No dysfunction (e.g., full capacity), ___________ Dysfunction _________________ duration = # _______________ weeks. _________________ type: __________________working sub optimally, __________________ambulatory, __________________bedridden. 5. Disease and its relation to nutritional requirements Primary diagnosis (specify) _____________________________________________________________________ Metabolic demand (stress) : ____________ no stress, _________________low stress, ____________moderate stress, Shaimaa Elkholy, M.D. Cairo University

B. Physical (for each trait specify: 0 = normal, 1+ = mild, 2+ = moderate, 3+ = severe) : # __________________________________loss of subcutaneous fat (triceps, chest) # __________________________________muscle wasting (quadriceps, deltoids) # __________________________________ankle edema # __________________________________sacral edema # __________________________________ascites C. SGA rating (select one) : ________________________A = Well nourished ________________________B = Moderately (or suspected of being) malnourished ________________________C = Severely malnourished. Shaimaa Elkholy, M.D. Cairo University

4. Laboratory evaluation
Plasma proteins (albumin, pre-albumin, transferrin and coagulation factors). Fat soluble vitamins in alcoholic liver disease and cholestatic liver disease (primary biliary cirrhosis). Water soluble vitamins and minerals as thiamine is common in alcoholic liver disease. Creatinine ( marker of protein stores) In Cirrhosis there is hepatic creatine synthesis, muscle mass, and tubular creatinine secretion. Shaimaa Elkholy, M.D. Cairo University

5. Anthropometry Bedside tool used to assess body fat and lean tissue stores that is largely unaffected by salt and water overload that indirectly estimates body composition. Most of RCT showed that anthropometry: Improved the detection of malnutrition. Highly correlates with morbidity &mortality. Shaimaa Elkholy, M.D. Cairo University

Triceps skin fold thickness (TSFT): using skin fold caliber Shaimaa Elkholy, M.D. Cairo University

Steps for measuring MAC (mid arm circumference) Shaimaa Elkholy, M.D. Cairo University

The tape is wrapped around the mid-arm mark. Shaimaa Elkholy, M.D. Cairo University

6. Miscellaneous DEXA scan: Retains utility in the diagnosis of osteoporosis and osteomalacia, particularly in patients with cholestatic liver disease. Shaimaa Elkholy, M.D. Cairo University

Bioelectrical impedance analysis (BIA) Performed by applying electrodes to one arm and one leg or by standing on a special scale. Impedance is proportional to the length of the conductor and inversely related to the cross-sectional area of the conductor. Accuracy in placement of electrodes is essential because even small variations can cause relatively large errors in the measurement of impedance and corresponding errors in the estimate of body water. A variety of formulas have been developed to convert the impedance, which measures body water, into an estimate of fat content. Shaimaa Elkholy, M.D. Cairo University

Measuring BMI, fat% ,muscle% and visceral fat using body fat monitor. Data regarding height ,age & sex is entered. Shaimaa Elkholy, M.D. Cairo University

The Body Fat Monitor with Scale sends a safe, low-level electrical current through the body to calculate the amount of body fat tissue. This is known as the Bioelectrical Impedance (BI) then Your visceral fat ,muscle percentages are automatically calculated. Shaimaa Elkholy, M.D. Cairo University

Hand grip: Several studies have confirmed the importance of muscle strength as a predictive factor for malnutrition. Shaimaa Elkholy, M.D. Cairo University

ESPEN Guidelines on Enteral Nutrition: CLD (steato hepatitis)
General : Use simple bedside methods such as the SubjectiveGlobal Assessment (SGA) or anthropometry to identify patients at risk of undernutrition. Recommended energy intake: 35–40 kcal/kg BW/d Recommended protein intake: 1.2–1.5 g/kgBW/d Shaimaa Elkholy, M.D. Cairo University

ESPEN Guidelines on Enteral Nutrition: CLD (liver cirrhosis)
General : Use simple bedside methods such as the Subjective Global Assessment (SGA) or anthropometry to identify patients at risk of undernutrition. Body cell mass measured by (BIA) to quantitate undernutrition, despite some limitations in patients with ascites. Recommended energy intake: 35–40 kcal/kg BW/d Recommended protein intake: 1.2–1.5 g/kgBW/d Shaimaa Elkholy, M.D. Cairo University

Nutritional support in liver cirrhosis Compensated cirrhosis: 25– kcal/kg/d 1.0– g/kg/d Inadequate intake or malnutrition: 35–40 kcal/kg/d g/kg/d Encephalopathy I–II: 35–40 kcal/kg/d g/kg/d if protein intolerant: vegetable protein or BCAA supplement Encephalopathy III–IV: 0.5 g/kg/d BCAA-enriched amino acid solution is recommended Shaimaa Elkholy, M.D. Cairo University

ESPEN Guidelines on Enteral Nutrition: pre transplant & surgery
General : Use simple bedside methods such as the Subjective Global Assessment (SGA) or anthropometry to identify patients at risk of undernutrition. Body cell mass measured by (BIA) to quantitate undernutrition, despite some limitations in patients with ascites. Shaimaa Elkholy, M.D. Cairo University

ESPEN Guidelines on Enteral Nutrition: pre transplant & surgery
Preoperative Follow recommendations for cirrhosis. Postoperative Initiate normal food/enteral nutrition within12–24 h postoperatively. Recommended energy intake: 35–40 kcal/kgBW/d Recommended protein intake: 1.2–1.5 g/kgBW/d Shaimaa Elkholy, M.D. Cairo University

Take home message Shaimaa Elkholy, M.D. Cairo University

PEM is highly prevalent among patients with liver cirrhosis is directly correlated to the degree & severity of the disease. Complications of liver cirrhosis are highly correlated to degree of malnutrition. There are several tools for nutritional assessment in cirrhotic but yet there is no gold standard one. SGA is a simple bedside tool commonly used. yet anthropometric measures e.g. TSFT &MAC are showing higher sensitivity & specificity. Shaimaa Elkholy, M.D. Cairo University

Thank you Thank you Shaimaa el kholy Shaimaa Elkholy, M.D. Cairo University

Nutritional assessment in chronic liver disease

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