Summary
The purpose of this article is to present detailed data on the nutritional assessment in cirrhotic patients. The exact frequency and types of malnutrition, its associations with the aetiology of liver disease, liver dysfunction and clinical staging in liver cirrhosis are unknown. A new classification system is presented which may help to suggest some interventional guidelines. Physical (anthropometry, 24-h urinary creatinine excretion, bioelectrical impedance analysis (BIA), total body potassium counting, ultrasound examination) and metabolic (indirect calorimetry) assessment of nutritional status was therefore performed in 123 patients with liver cirrhosis, who were considered as potential candidates for liver transplantation. Data were related to the clinical, biochemical, histological and prognostic data of liver disease. Of our patients 65% showed some signs of protein-calorie malnutrition as indicated by low body cell mass, reduced serum albumin concentrations or abnormal skinfold thickness. Of these 34% were considered as “kwashiorkor-like” (normal body composition, serum albumin <35 g/1), and 18% were “marastic” (reduced body weight, body cell mass, and fat mass). However, 49% of the malnourished group had reduced body cell mass in association with increased fat mass and frequently presented with a normal body weight (“mixed” or “obese” type). Protein-calorie malnutrition did not correlate with the aetiology of the disease and biochemical parameters of liver function. Malnutrition was observed at all clinical stages but was more frequently seen at advanced stages. We conclude that malnutrition associated with liver cirrhosis is not a clear phenomenon. Its clinical presentation is heterogenous and not reflected by the histological or biochemical parameters of liver disease. Since malnutrition is rarely diagnosed, early and detailed nutritional assessment in all patients with liver disease is important.
Similar content being viewed by others
Abbreviations
- AMA:
-
arm muscle area
- ALT:
-
alanine aminotransferase
- AST:
-
aspartate aminotransferase
- BCM:
-
body cell mass
- BIA:
-
bioelectrical impedance analysis
- BMI:
-
body mass index
- BW:
-
body weight
- CHE:
-
cholinesterase
- FFM:
-
fat free mass
- ICG:
-
indocyanine green
- LBM:
-
lean body mass
- MAC:
-
mid-arm circumference
- MEGX:
-
monoethylglycinexylidide
- PTT:
-
prothrombin time
- TBP:
-
total body potassium
- TSF:
-
triceps skinfold
References
Böhm D, Odaishi M, Beyerlein C (1989) Impedanzmessung zur Bestimmung des Körperwassergehaltes. Infusionstherapie 16:25–32
DiCecco SR, Wieners EJ, Wiesner R, Southern PA, Plevak DJ, Krom RAJ (1989) Assessment of nutritional state of patients with end-stage liver disease undergoing liver transplantation. Mayo Clin Proc 64:95–102
Forbes GB (1987) Human body composition. Springer, Berlin Heidelberg New York
Heymsfield SB, Waki M (1991) Body composition in humans: advances in the development of multicompartment chemical models. Nutr Rev 49:97–108
Heymsfield SB, Waki M, Reinus J (1990) Are patients with chronic liver disease hypermetabolic? Hepatology 11:502–505
Lantz HU, Pichlmayr R (1989) Special aspects of timing of liver transplantation in patients with liver cirrhosis. Baollieres Clin Gastroenterol 3:743–756
Lautz HU, Schmidt FW, Muffler MJ, Pichlmayr R (1989) Indikationen und Kontraindikationen der Lebertransplantation. DMW 114:1456–1461
Lohmann TG, Roche AF, Martorell R (1988) Anthropometric standardization reference manual. Human Kinetics Books, Champaign
McCullough AJ, Mullen KD, Smanik EJ, Tabbaa M, Szauter K (1989) Nutritional therapy and liver disease. Gastroenterol Clin North Am 18:619–643
McIntyre N (1987) Undernutrition and malnutrition in cirrhosis. In: Tygstrup N, Orlandi F (eds) Cirrhosis of the liver: methods and fields of research. Elsevier, Amsterdam, pp 225–234
Mendenhall CL, Anderson S, Weesner RE, Goldberg SJ, Crolic KA (1984) Protein-calorie malnutrition associated with alcoholic hepatitis. Veterans Administration Cooperative Study Group on Alcoholic Hepatitis. Am J Med 76:211–222
Miholic J, Meyer HJ, Miller MJ, Weinmann A, Pichlmayr R (1990) Nutritional consequences of total gastrectomy: the relationship between mode of reconstruction, postprandial symptoms, and body composition. Surgery 108:488–494
Muller MJ, Acheson KJ, Jequier E, Burger AG (1988) Effect of thyroid hormones on oxidative and nonoxidative glucose metabolism in humans. Am J Physiol 255:E146-E155
Muller MJ, Muhlen A von zur, Lautz HU, Schmidt FW, Daiber M, Hürter P (1989) Energy expenditure in children with type 1 diabetes mellitus: evidence for increased thermogenesis. Br Med J 299:487–491
Müller MJ, Fenk A, Lantz HU, Selberg O, Canzler H, Balks HJ, Muhlen A von zur, Schmidt E, Schmidt FW (1991) Energy expenditure and substrate metabolism in ethanol-induced liver cirrhosis. Am J Physiol 260: E338-E344
Muffler MJ, Lautz HU, Burger M, Plogmann B, Körber J, Schmidt FW (1992) Resting energy expenditure, malnutrition and liver function in patients with liver cirrhosis. Hepatology 15 (May issue)
Müller MJ, Lautz HU, Selberg O, Canzler H, Schmidt FW (1991) Ernährung bei chronischen Lebererkrankungen. Dtsch Med Wochenschr 116:909–916
Muto Y, Yoshida T, Yamatoh M (1990) Nutritional treatment of liver cirrhosis with branched chain amino acids (BCAA). In: Tanaka T, Okada A (eds) Nutritional support in organ failure. Elsevier Science, Excerpta Medica, Amsterdam, pp 267–276
Oellerich M, Raude E, Burdelski M, Schulz M, Schmidt FW, Ringe B, Lamesch P, Pichlmayr R, Raith H, Schwerun M, Wrenger M, Wittekind C, Klawuhn B, Knoke A, Maus M, Farle M (1987) Monoethylglycinexilidide formation kinetics: a novel approach to assessment of liver function. J Clin Chem Biochem 25:845–853
Pugh RNH, Murray-Lyon IM, Dawson JL, Pietron MC, Will R (1973) Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 60:646–649
Richardson RA, Fearon KCH, Hannan J, Cowan S, Watson W, Shenkin A, Garden OJ (1990) Estimation of body cell mass (BCM) in surgical patients by bioelectrical impedance analysis (BIA) compared with total body potassium (TBK) (abstract). Clin Nutr 9 [Spec suppl]: 74
Roubenoff R, Kehayias JJ (1991) The meaning and measurement of lean body mass. Nutr Rev 49:163–175
Shizgal HM (1990) Validation of the measurement of body composition from whole body bioelectrical impedance. Infusionstherapie 17 [Supp13]:67–74
Wagner S, Lantz HU, Muller MJ, Schmidt FW (1991) Pathophysiology and clinical basis of prevention and treatment of complications of chronic liver disease. Klin Wochenschr 69:112–120
Author information
Authors and Affiliations
Additional information
This work was supported by B. Braun Stiftung and B. Braun Melsungen A.G., Melsungen, FRG
Rights and permissions
About this article
Cite this article
Lautz, H.U., Selberg, O., Körber, J. et al. Protein-calorie malnutrition in liver cirrhosis. Clin Investig 70, 478–486 (1992). https://doi.org/10.1007/BF00210228
Received:
Revised:
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF00210228