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nutrition issues in gastroenterology series 204 nutrition issues in gastroenterology series 204 carol rees parrish ms rdn series editor nutrition considerations in the cirrhotic patient eric b martin matthew j ...

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        NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #204                                                                                                                             NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #204
         Carol Rees Parrish, MS, RDN, Series Editor
          Nutrition Considerations 
          in the Cirrhotic Patient
              Eric B. Martin                            Matthew J. Stotts
         Malnutrition is commonly seen in individuals with advanced liver disease, often resulting from 
         a combination of factors including poor oral intake, altered absorption, and reduced hepatic 
         glycogen reserves predisposing to a catabolic state. The consequences of malnutrition can be 
         far reaching, leading to a loss of skeletal muscle mass and strength, a variety of micronutrient 
         deficiencies, and poor clinical outcomes. This review seeks to succinctly describe malnutrition 
         in the cirrhosis population and provide clarity and evidence-based solutions to aid the bedside 
         clinician. Emphasis is placed on screening and identification of malnutrition, recognizing 
         and  treating  barriers  to  adequate  food  intake,  and  defining  macronutrient  targets.
         INTRODUCTION
         The Problem
            ndividuals with cirrhosis are at high risk of           patients to a variety of macro- and micronutrient 
            malnutrition for a multitude of reasons. Cirrhotic      deficiencies as a consequence of poor intake and 
         Ilivers lack adequate glycogen reserves, therefore         altered absorption.
         these individuals rely on muscle breakdown as an               As liver disease progresses, its complications 
                                                              1
         energy source during overnight periods of fasting.         further increase the risk for malnutrition. Large 
         Well-meaning providers often recommend a variety           volume ascites can lead to early satiety and decreased 
         of dietary restrictions—including limitations on           oral intake. Encephalopathy also contributes to 
         fluid, salt, and total calories—that are often layered     decreased oral intake and may lead to inappropriate 
         onto pre-existing dietary restrictions for those           recommendations for protein restriction. Frequent 
         with co-existent conditions such as diabetes or            hospitalizations and procedures can lead to 
         renal disease. Furthermore, different underlying           periods of prolonged fasting. In combination, the 
         etiologies of liver disease, such as heavy alcohol         physiology of liver disease and its consequences 
         use and chronic cholestasis, predispose cirrhotic          lead to a prevalence of malnutrition in the cirrhotic 
                                                                    population that has been described as nearly 
         Eric B. Martin MD, MBA, Fellow Physician, PGY 5,           universal in those awaiting liver transplantation 
         Cleveland Clinic, Respiratory Institute, Critical          (LT), and so high in all individuals with cirrhosis 
         Care, Cleveland, OH Matthew J. Stotts MD. MPH.             that current guidelines recommend anticipating 
         Assistant Professor of Medicine, University of             malnutrition, protein depletion, and trace element 
                                                                                 1,2
         Virginia Health System, Charlottesville, VA                deficiencies.
         14                                                             PRACTICAL GASTROENTEROLOGY • NOVEMBER 2020
                                                               Nutrition Considerations in the Cirrhotic Patient
NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #204  NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #204
            The consequences of malnutrition are wide             Table 1. Comprehensive Nutritional Assessment
        ranging. Sarcopenia can become one of the more                                        Low Strength 
        obvious and discouraging physical changes patients                               (sarcopenia probable)
        and families notice. An abundance of evidence                                             AND
        links low body mass index (BMI), frailty, and               Sarcopenia        Low Muscle quantity/quality 
        progressive sarcopenia with poor outcomes after             Assessment          (sarcopenia confirmed)
                              3,4
        liver transplantation.  Micronutrient deficiencies                                        WITH
        can lead to a variety of consequences, ranging from 
        anemia to increased bone fracture risk to altered                              Low physical performance 
        taste. In this setting, identification of malnourished                            (severe sarcopenia)
        individuals coupled with targeted nutritional                                           RFH-GA 
        interventions are critical to improving quality of             Global                      OR
        life and optimizing clinical outcomes in individuals        Assessment 
                        5                                                                         SGA 
        with cirrhosis.
        The Practical Approach to                                     Dietary                     1 Day
        Nutrition in Liver Disease                                 Intake Report                   OR
                                                                                                  3 Day
        Screen for Malnutrition 
        A typical clinical encounter with a patient afflicted     Table 2. Liver Frailty Index
        by advanced liver disease often requires careful              Handgrip Strength – Jamar Dynamometer
        consideration of their primary liver disease,                  With Dynamometer in 2nd position, take 
        management of liver decompensations, ensuring                 average of 3 attempts with dominant hand
        that appropriate screening of esophageal varices and 
        hepatocellular carcinoma has been completed, and                               Chair Rise
        determining whether liver transplantation referral         Record time to do 5 chair stands (1 to 60 secs);
        or end-of-life care is appropriate. An important yet                         If fails, then 0
        often overlooked facet of these complex encounters                        3 Position Balance
        is consideration of the patient’s nutritional risk. 
            All patients with advanced liver disease should                  Side-by-side for 0 to 10 secs
                                          6
        be screened for malnutrition.  Decompensated                      Semi-tandem stance for 0 to 10 sec
                                                         2
        cirrhotics and those with a BMI of ≤ 18.5 kg/m  are                 Tandem stance for 0 to 10 sec
                                                       6,7
        considered high risk regardless of screening.  If a 
        patient does not meet either of the aforementioned 
        criteria, multiple screening tools can be used to         mass and function due to age or illness, is likely 
        stratify patients according to their nutritional risk.    present when low muscle strength is detected and 
        The Royal Free Hospital-Nutrition Prioritizing            is confirmed when low muscle quantity or quality 
                                                                           6,10
        (RFH-NP) tool is easy to administer, validated            is found.    Handgrip strength has been shown to 
        in the cirrhotic population, and has been shown           correlate with strength in other body compartments, 
                                                8,9
        to correlate with disease severity.  In those             and is a cheap, fast, and validated method for 
        identified as moderate or high nutritional risk, a        evaluating muscle strength.10 Handgrip strength 
        comprehensive nutritional assessment should be            has also been shown to predict major complications 
                                              6                                                                  11
        conducted by a registered dietitian.                      and mortality in the cirrhotic population.  An 
            As outlined  in Table  1,  a  comprehensive           accepted alternative is the chair rise test, defined 
        nutritional assessment should include evaluation          as the amount of time needed for a patient to rise 
                                                                                           10
        for sarcopenia (e.g. lean muscle mass), use of a          from a chair five times.  The Liver Frailty Index 
        global assessment tool (GA), and review of the            is an increasingly used easy tool that combines 
                                               6
        patient's self-reported dietary intake.  Sarcopenia,      hand grip strength, chair rise time, and ability to 
        defined as a generalized reduction in muscle              stand in different positions into a single metric to 
        PRACTICAL GASTROENTEROLOGY • NOVEMBER 2020                                                                  15
         Nutrition Considerations in the Cirrhotic Patient
         NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #204
        Table 3. Symptom Based Nutrition Barriers
         Symptom                       Consideration                 Recommendations 
         Anorexia                      Ascites                       Ascites management 
                                       Food access                   Psychosocial support 
                                       Psychiatric disease           Consultation  
         Dysguesia                     Vit. A, Zinc, Magnesium       Replete deficiencies
                                       Salt usage                    Salt substitutes 
                                                                     (careful with potassium containing)
                                                                     Lessen salt restrictions 
         Early Satiety                 Ascites                       Ascites management 
                                       Meal size                     Small meals with snacks
                                       Gastroparesis                 Start a promotility agent
                                                                     Calorie dense supplements 
         Poor Sleep Quality            Sleep hygiene                 Optimize environment
                                                                     Consider melatonin
                                       Diuretic timing               Morning diuretic dosing
        classify patients as robust, pre-frail, and frail, and  on dietary restrictions, but rather healthy eating 
        has been validated in the liver transplant population   patterns that emphasize high vegetable, fruit, 
                                                        12,13                               1,6
        (see Table 2; https://liverfrailtyindex.ucsf.edu).      protein, and caloric intake.  Eating a wide variety 
        The  second  component  of a comprehensive              of enjoyable foods and avoiding the addition of 
        nutritional assessment are GA tools, which seek         salt or foods with a high sodium content is a 
        to diagnose varying levels of malnourishment from       reasonable strategy to minimize the consequence 
        history and physical. The most common GA tools          of salt restriction’s typical negative impact on 
                                                                                            1,6
        deployed in clinical practice are the subjective        caloric and protein intake.  In addition, a variety 
        global assessment (SGA) and the Royal Free              of disease related barriers are important to consider 
        Hospital-global assessment (RFH-GA).14 Given            when discussing nutrition with these patients, each 
        that the RFH-GA is time consuming and requires a        of which has important treatment considerations 
        registered dietitian, the SGA is generally easier to    that can positively impact the patient’s nutritional 
        administer and is a reasonable alternative despite      intake (see Table 3).
        weak validation in the cirrhotic population.1 To            In cases where oral intake is insufficient to meet 
        complete the nutritional assessment, a review of        caloric demands, enteral nutrition (EN; via naso- 
        self-reported dietary intake should be conducted.       and orogastric tubes) or parenteral nutrition (PN) 
        Dietary intake surveys provide insight into the         may be required. The most commonly encountered 
        amount, type, and timing of food consumption            scenario where oral intake is insufficient occurs 
        and can provide valuable insight into barriers to       in hospitalized patients. For patients who do 
                            6
        adequate nutrition.                                     not have evidence of gastrointestinal bleeding, 
        Barriers and Routes of Feeding                          naso- or orogastric tube placement should occur 
                                                                immediately after intubation and can be considered 
        Oral  intake  is  the  desired  mode  of  nutrient      safe regardless of variceal history.1,6 In those 
        consumption for a variety of physiologic and            with gastrointestinal (GI) bleeding secondary to 
        psychologic reasons, and consistent messaging           esophageal varices, it is prudent to wait 48 to 
        regarding the importance of adequate nutrition          72 hours after banding prior to placing a gastric 
                                                                      15
        should be emphasized in all cirrhotic patient           tube.  In other types of GI bleeding, gastric 
        encounters. In general, advice should not focus         tube placement is generally reasonable 24 hours 
        16                                                           PRACTICAL GASTROENTEROLOGY • NOVEMBER 2020
                                                                  Nutrition Considerations in the Cirrhotic Patient
                                                      NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #204
         Table 4. Caloric and Protein Goals by Disease State*
                                       Compensated          Obese         Malnourished      Pre- & Post-      Critically Ill 
                                                   1                2      Sarcopenic         Operative 
                                         Cirrhotic         Cirrhotic         Cirrhotic        Cirrhotic         Cirrhotic 
                                               † 3              †                                   †                   †
          Calories (kcal/kg/day)           ≥35              25 **            30-35**          30-35 **          ≥35-40 
                                                                  †                                  †                † 
          Protein (g/kg/day)               1.2**          2.0-2.5 **          1.5**          1.2-1.5 **          ≥1.2 
         1. In the compensated (i.e. euvolemic) cirrhotic, actual body weight can be used to estimate energy and protein provision
         2. Both EASL and ESPEN base energy and protein provision in the obese on ideal body weight (IBW)
         3. Caloric  provision  in  the  cirrhotic  is  recommended  to  be  based  on  resting  energy  expenditure  (REE)  as  determined  by  indirect 
             calorimetry (IC). ESPEN recommends providing 1.3 x REE kcal/kg/day; EASL succinctly recommends not less than 35 kcal/kg/day
           *Always assess refeeding risk prior to initiating feeding
         **ESPEN guideline on clinical nutrition in liver disease (1)
         †
          EASL clinical practice guidelines on nutrition in chronic liver disease (6)
         after bleeding cessation. Conversion to post-                actual body weight may be used. In decompensated 
         pyloric feeding should occur in those who cannot             (i.e. hypervolemic) patients, current guidelines 
         tolerate gastric feeding despite efforts to improve          are somewhat discordant on the recommended 
                                                           16
         tolerance or are at high risk for aspiration.  In            approach. The European Association for Study of 
         the outpatient setting, if oral intake is insufficient,      the Liver (EASL) recommends using an adjusted 
         feeding tubes can be maintained for considerable             body weight based on the amount of ascites and 
         periods of time with minimal supervision, although           peripheral edema (subtracting 5% if mild ascites, 
         insurance infrequently covers tube-feeding in                10% if moderate, and 15% if severe, as well as an 
         the  pre-transplant  population.  Percutaneous               additional 5% if pedal edema is present), whereas 
         enteral gastrostomy (PEG) tubes are generally                the European Society for Clinical Nutrition and 
         contraindicated in cirrhosis due to bleeding risks           Metabolism (ESPEN) recommends using the 
         (i.e. gastric varices) and infectious complications          ideal body weight (IBW), which is based on the 
                                                                                                       1,6
         (especially in the setting of ascites) and should only       patient’s gender and height.  When obesity is 
         rarely be employed.1,6 Parenteral feeding should             present, both societies recommend using IBW. 
         only be used when enteral feeding cannot meet the            With these different approaches in mind, weight-
                                                                1
         patient’s energy demands or is contraindicated.              based caloric and protein recommendations can be 
         In addition to standard trace elements and the               found in Table 4.
         multivitamin and mineral supplements provided                    Oral nutrition supplementation and attention 
         with PN, all patients requiring PN should receive            to meal timing are important considerations when 
         vitamin K and higher doses of thiamine if actively           helping patients achieve recommended protein and 
         drinking.                                                    calorie goals. Use of protein additives, frequent 
                                                                      small meals, and ingestion of high protein foods 
         Calorie and Protein Goals and Strategies                     are common tactics employed in this patient 
         Once a patient is determined to be nutritionally at          population. Importantly, a late evening snack (LES) 
         risk or malnourished, they should receive targeted           has been shown to improve lean muscle mass and 
         nutritional interventions that provide tailored              should be routinely recommended to cirrhotic 
         strategies to achieve proper caloric and protein             patients. The LES should occur between 9pm and 
                 5,6
         intake.                                                      11pm and contain between 500 to 700 kcal with 
                                                                                                             17,18
             Caloric and protein intake recommendations               at least 50 grams of carbohydrates.
         are ideally based on indirect calorimetry, but due 
         to limited availability weight-based targets are             The When and How of Micronutrients
         typically used.  Weights taken after a paracentesis          Macronutrient  deficiencies  are  not  the  only 
         or at a time of euvolemia are considered dry                 dietary shortfall in cirrhotics. Micronutrients, 
         weight, and may be used for weight-based                     a broad nutrient class that includes dietary 
         energy and protein provision.1 If no dry weight              elements (minerals, trace elements) and organic 
         is available, but the patient is near euvolemia,             compounds (vitamins) that are required in small 
         PRACTICAL GASTROENTEROLOGY • NOVEMBER 2020                                                                       17
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...Nutrition issues in gastroenterology series carol rees parrish ms rdn editor considerations the cirrhotic patient eric b martin matthew j stotts malnutrition is commonly seen individuals with advanced liver disease often resulting from a combination of factors including poor oral intake altered absorption and reduced hepatic glycogen reserves predisposing to catabolic state consequences can be far reaching leading loss skeletal muscle mass strength variety micronutrient deficiencies clinical outcomes this review seeks succinctly describe cirrhosis population provide clarity evidence based solutions aid bedside clinician emphasis placed on screening identification recognizing treating barriers adequate food defining macronutrient targets introduction problem ndividuals are at high risk patients macro for multitude reasons as consequence ilivers lack therefore these rely breakdown an progresses its complications energy source during overnight periods fasting further increase large well m...

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