Applied nutritional investigationNutrition and survival in patients with liver cirrhosis☆
Introduction
Malnourished patients with liver disease have long been recognized as being at greater risk for postoperative complications and increased mortality. A subjective nutritional assessment was one of five variables used for estimating survival after vascular-shunt surgery in the initial classification of Child and Turcotte.1 The relation between nutrition status and surgical risk has been confirmed in cirrhotic patients undergoing portacaval shunt,2 non-shunt laparotomies,3 and liver transplantation.4, 5
Other studies have demonstrated that malnutrition is related to poorer survival in patients with alcoholic hepatitis. A composite score that included a number of nutrition parameters (e.g., albumin, transferrin, lymphocyte count, and skin test) correlated significantly with patient survival in the two studies by Mendenhall et al.6, 7 Insulin-like growth factor-18 and thyroid hormones9 have been found to predict survival in patients with liver cirrhosis. However, most parameters used for nutrition assessment are influenced by liver disease and its complications, so that it is difficult to separate the effects of malnutrition per se from the effects of liver disease. Anthropometric parameters based on midarm-muscle circumference (MAMC) and triceps skinfold thickness (TSF) are not affected by non-nutritional factors that can confound the interpretation of other indices such as body weight, plasma protein concentrations, and immunologic tests. MAMC and TSF can be measured fairly accurately in patients with advanced liver disease and fluid retention because edema accumulates to a lesser extent in the upper extremities. Intra- and interobserver errors, the major limitations of measurements based on TSF, can be minimized if the method is standardized and the observer is experienced. At present, MAMC and TSF are considered the most reliable “bedside” techniques to assess nutrition status in those with liver disease.10, 11 Two recent reports focused on the prognostic value of these parameters,12, 13 but anthropometric parameters were found to be independent predictors of survival in only one of these studies.13 We investigated whether reduced MAMC and TSF are independent predictors of survival in cirrhotic patients and whether including these parameters in the Child-Pugh score could improve its prognostic accuracy.
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Subjects
Two hundred twelve (143 male, 69 female) consecutive hospitalized patients with liver cirrhosis were included in the study. The diagnosis of cirrhosis was based on clinical, laboratory, and ultrasonographic criteria and histologically confirmed in 98 patients. Patients with hepatocellular carcinoma were excluded, as were patients with anasarca and edema extending to the upper extremities. Patients hospitalized because of acute diseases or complications related to liver impairment were evaluated
Nutrition status
Nutrition parameters of patients grouped according to the severity of liver disease are shown in Table II. Seventy-two cirrhotic patients (34%) were below the 5th percentile for MAMC and/or TSF and 20% were below the 10th percentile for MAMC and/or TSF. The prevalence of severe malnutrition was higher in Child-Pugh class C (36 of 79, 45.5%) than in Child-Pugh class A (6 of 48, 12.5%; P < 0.001) or class B (30 of 85, 35.2%; P < 0.01). Fifty-five (26%) patients were overnourished, with MAMC
Discussion
Twenty-six percent of our patients were overnourished, with arm-anthropometric values above the 75th percentile. The prevalence of patients defined as overnourished according to BMI was even higher (49%), but nutrition parameters derived from body weight are unreliable in patients with ascites and fluid retention, so BMI was not taken into account to evaluate survival in our patients.
Malnutrition was a common complication in advanced stages of liver disease and progressively increased from
Acknowledgements
The authors are grateful to Antonietta Sticca for technical assistance.
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This work was supported by grants from the Ministero dell’Università e della Ricerca Scientifica e Tecnologica (MURST).