Malnutrition in end stage liver disease : Who is malnourished?

Liver diseases are highly prevalent. While death rates of most other diseases, such as heart disease and cancer, have decreased, standardized mortality rates of liver diseases have increased up to 400% in the last decades. Cirrhosis is the endstage of patients who have chronic progressive liver disease, with a high risk of complications and high mortality rates. While liver transplantation is a treatment option, still nearly 17% of patients yearly die while on the waiting list. In addition, many patients are not eligible for transplantation due to comorbidities, substance abuse, mental illness, insufficient psychosocial support and overall physical condition. Therefore, anything keeping patients with liver disease in the best possible physical condition is needed. Nutrition plays an important role here, especially since malnutrition is highly prevalent in these patients. We found that the standard definition of malnutrition in these patients, protein energy malnutrition, is no longer useful. Protein energy malnutrition indicates an insufficiency of both energy and protein (true protein energy malnutrition) or an insufficiency of protein (protein malnutrition) with sufficient energy. It makes, however, no distinction between these two types of malnutrition and neglects (severe) overweight and combinations of malnutrition. The prevalence of true protein energy malnutrition is only 8%, whereas the prevalence of the other types of malnutrition is extremely high (71%). However, these latter types of malnutrition are associated with the highest mortality rates. (Severe) overweight is, in itself, a cause of liver disease and deteriorates existing liver disease. As a step towards improving recognition of the different types, we propose a differentiation in the definition based on body protein and fat mass. Current diagnostic tools cannot differentiate between these types. We show that the Jamar hand grip strength, a marker for protein malnutrition, is an independent predictor of complications in cirrhotics. We propose a combination of inexpensive and simple markers, including hand grip strength, for a correct diagnosis. Current nutritional guidelines also need to be updated as they focus only on true protein energy malnutrition, calling for both energy and protein enrichment. This is accurate in only 8% of patients with cirrhosis. These guidelines do not differentiate between the different types of malnutrition in cirrhosis and ignore (severe) overweight. Following these guidelines may actually exacerbate liver disease in 61% of cirrhotics; those with an already high body fat mass. We provide ‘proof of concept’ that specific nutritional support, based on a correctly diagnosed nutritional status, can preserve the nutritional status including handgrip strength, even during a long and arduous peginterferon-containing treatment for chronic hepatitis C. Preventive nutritional support improves digestive symptoms and quality of life and reduces side effects. It also markedly ameliorates a decrease of labour productivity, physical exercise and performance status during HCV antiviral therapy. Nutritional therapy is not only cost effective; it may reduce costs due to loss of labour productivity with almost 50%. We recommend that future research should focus on validation of the proposed diagnostic tools, preservation of the nutritional status during other arduous treatments and treating existing malnutrition with specific nutritional support.