Changes in nutritional status after liver transplantation

Table 1 Prevalence of muscle depletion in cirrhotic patients and related outcomes

Ref.	Patients (n)	Definition of muscle depletion	Prevalence of muscle depletion	Outcome associated with muscle depletion
Merli et al[5], 1996	1053	Mid Arm Muscle Area < 5thP	26%	Lower survival in Child A and Child B
			38% M; 8% F
Alberino et al[13], 2001	212	Mid Arm Muscle Area < 5thP	25%	Lower survival at 6, 12 and 24 mo
		Mid Arm Muscle Area < 10thP	37%
Alvares-da-Silva et al[14], 2005	50	Hand-Grip Strength 2 SDs below the mean value for the controls	63%	Higher rate of major complications
Campillo et al[15], 2006	396	Mid Arm Muscle Area < 5thP	53.2%	No correlation with in-hospital mortality
			Child Pugh A:
			74.3% M, 22.2% F;
			Child Pugh B:
			68.9% M, 35.2% F;
			Child Pugh C:
			54.7% M, 21.9% F
Peng et al[16], 2007	268	Protein Index < 0.82 or 2 SDs below the mean protein index for the controls	51%	No outcome evaluated
			63% M; 28% F
			Child Pugh A: 72%;
			Child Pugh B: 43%;
			Child Pugh C: 42%
Huisman et al[17], 2011	84	Hand-Grip Strength	67%	Higher risk of complications
		Mid Arm Muscle Circumference	58%
Fernandes et al[20], 2012	129	Mid Arm Muscle Circumference	13.2%	No outcome evaluated
		Hand-Grip Strength 2 SDs below the mean value for the controls	69.3%
Montano-Loza et al[18], 2012	112	Lumbar Skeletal Muscle Mass Index at CT scan ≤ 38.5 cm2/m2 in women and ≤ 52.4 cm2/m2 in men	40%	Increased 3 and 6 mo mortality
			50% M; 18% F
			Child Pugh A: 13%;
			Child Pugh B: 55%;
			Child Pugh C: 32%
Tandon et al[19], 2012	142	Lumbar Skeletal Muscle Mass Index at CT scan ≤ 38.5 cm2/m2 in women and ≤ 52.4 cm2/m2 in men	41%	Increased mortality in cirrhotic patients awaiting liver transplantation
			54% M; 21% F
			Child Pugh A: 0% M, 14% F;
			Child Pugh B: 42% M, 21% F;
			Child Pugh C: 72% M, 23% F
Merli et al[21], 2013	300	Mid Arm Muscle Circumference < 5thP	39%	Higher rate of hepatic encephalopathy

M: Male; F: Female; CT: Computed tomography.

Table 2 Mechanisms that cause a reduction in food intake in patients with cirrhosis

Reduced nutrient intake	Decreased appetite and anorexia	Unpalatable diet (sodium and water restriction for peripheral oedema and ascites, protein restriction for hepatic encephalopathy)
		Dysgeusia due to micronutrient deficiencies (zinc or magnesium)
		Anorexic effect caused by increased levels of proinflammatory cytokines (TNFα, IL-1β, IL-6) and leptin
	Nausea and early satiety	Tense ascites
		Gastroparesis
		Small bowel dysmotility
		Bacterial overgrowth
	Frequent compulsory starvation	Hospitalisation
		Invasive diagnostic procedures requiring fasting
		Gastrointestinal bleeding and endoscopic therapy

TNF: Tumor necrosis factor α; IL: Interleukin.

Table 3 Vitamins and trace elements deficiencies in patients with cirrhosis

	Mechanism of deficiency	Primary consequences
Water soluble vitamins
Complex B and	Dietary insufficiency	Wernicke’s encephalopathy and Korsakoff dementia, anaemia, asthenia, scurvy
Vitamin C	Intestinal dysmotility
Fat soluble vitamins
Vitamin A (Retinol) and vitamin E	Dietary insufficiency	Risk factor for developing cancer, including hepatocellular carcinoma, night blindness
	Malabsorption for cholestasis or due to medications (i.e., cholestyramine)
Vitamin D	Dietary insufficiency	Osteopenia and osteoporosis
	Malabsorption for cholestasis or due to medications (i.e., cholestyramine, steroids)
Vitamin K	Reduced exposure to UV light	K-dependent coagulation factors deficiency (II, VII, IX, X)
	Dietary insufficiency
	Malabsorption for cholestasis or due to medications (i.e., cholestyramine)
Trace elements
Zinc	Dietary insufficiency	Contribution to impaired glucose tolerance and diabetes, precipitation of hepatic encephalopathy
	Malabsorption (intestinal dysmotility)
	Diuretic induced increased urinary excretion
Magnesium	Dietary insufficiency	Loss of muscle strength
	Malabsorption (intestinal dysmotility)

UV: UltraViolet.

Table 4 Relationship between nutritional status and outcome after liver transplantation

Ref.	Patients (n)	Parameters used for the assessment of nutritional status	Prevalence of malnutrition	Outcomes related to malnutrition
Pikul et al[64],1994	68	Subjective Global Nutritional Assessment	79%	Prolonged ventilator support
				Increased incidence of tracheostomy
				More days in intensive care unit and hospital
Selberg et al[65], 1997	150	Anthropometry	41%-53%	Decreased 5-yr survival after liver transplantation
		Body composition analysis
		Indirect calorimetry
Harrison et al[66], 1997	102	Anthropometry	79%	Higher risk of infections
		Dietary intake
		Figueiredo et al[7], 2000			53	Subjective Global Nutritional Assessment	87%	More days in intensive care unit
Hand-grip strength	Increased incidence of infections
Body composition analysis
Stephenson et al[68], 2001	99	Subjective Global Nutritional Assessment	100%	Increased blood product requirement
				More days in hospital
Shahid et al[28], 2005	61	Hand-grip strength	Not reported	No correlation
		Anthropometry
de Luis et al[69], 2006	31	Subjective Global Nutritional Assessment	Not reported	No correlation
		Body composition analysis
		Dietary intake
Merli et al[70], 2010	38	Subjective Global Nutritional Assessment	53%	More days in intensive care unit and hospital
		Anthropometry		Increased incidence of infections
		Indirect calorimetry
		Dietary intake
Englesbe et al[71], 2010	163	Psoas muscle area (CT evaluation)	Not reported	Decreased 1-yr survival

CT: Computed tomography.