Protein Energy Malnutrition (PEM) is highly prevalent among patients with chronic liver disease. One of the problems is how to assess these patients nutritionally. yet no standard golden rule for their nutritional assessment.

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

2. 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

3. 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

4. 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

5. 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

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

7. 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

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

9. 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

10. 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

11. 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

12. Steps for nutritional assessment
• 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

13. Steps for nutritional assessment
• History
• Physical examination
• Subjective global
assessment
• Laboratory evaluation
• Anthropometry
• Miscellaneous tests
Shaimaa Elkholy, M.D. Cairo University

14. 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

15. 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

16. • 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.
2.Physical examination
Shaimaa Elkholy, M.D. Cairo University

17. • 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.
3. Subjective global
assessment
Shaimaa Elkholy, M.D. Cairo University

18. A.History
1. 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

19. 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

20. • 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.
4. Laboratory evaluation
Shaimaa Elkholy, M.D. Cairo University

21. • 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.
5. Anthropometry
• Most of RCT
showed that
anthropometry:
Improved the
detection of
malnutrition.
 Highly correlates with
morbidity &mortality.
Shaimaa Elkholy, M.D. Cairo University

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

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

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

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

26. 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

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

28. 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

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

30. 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

31. 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

32. Shaimaa Elkholy, M.D. Cairo University

33. Shaimaa Elkholy, M.D. Cairo University

34. Nutritional support in liver cirrhosis
 Compensated cirrhosis:
 25–35 kcal/kg/d
 1.0–1.2 g/kg/d
 Inadequate intake or malnutrition:
 35–40 kcal/kg/d
 1.5 g/kg/d
 Encephalopathy I–II:
 35–40 kcal/kg/d
 0.5- 1 g/kg/d if protein intolerant: vegetable protein or BCAA
supplement
 Encephalopathy III–IV:
 35–40 kcal/kg/d
 0.5 g/kg/d
 BCAA-enriched amino acid solution is recommended
Shaimaa Elkholy, M.D. Cairo University

35. 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

36. 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

37. Shaimaa Elkholy, M.D. Cairo University

38. Shaimaa Elkholy, M.D. Cairo University

39. Shaimaa Elkholy, M.D. Cairo University

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

41. 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

42. Thank you
Shaimaa Elkholy, M.D. Cairo University