ABSTRACT
Malnutrition is a very common manifestation of chronic liver disease, being very frequent in the early phases of cirrhosis and almost universal in end-stage liver disease (ESLD). Malnutrition is characterized by depletion of body fat and proteins, and dešciency of many micronutritients. It is associated with impaired short-term survival and impaired immunocompetence, and it is correlated with the typical manifestations of ESLD, including hepatic encephalopathy, ascites, and hepatorenal syndrome (Pikul et al. 1994). Pre-liver transplant nutritional status is independently associated with the number of infection episodes during the hospital stay (Gunsar et al. 2006). The presence of malnutrition is an independent risk factor for the length of stay in the Intensive Care Unit and the total number of days spent in hospital after liver transplant (Merli et al. 2009). Malnutrition is an often unrecognized complication of ESLD and even the most widely used methods to assess the severity of liver disease such as the Model for End Stage Liver Disease (MELD) and the Child-Pugh scores do not include specišc nutritional parameters. The etiologies of malnutrition in all forms of chronic liver disease fall into three general categories: decreased appetite with diminished nutrient intake, inadequate intestinal absorption with increased protein losses, and abnormal metabolism. The clinical evaluation of malnutrition includes history of weight loss of more than 10% of usual weight with the typical depletion of body fat and skeletal muscle mass which is more appreciated in the temporal region of the head and the proximal musculature of the extremities. Other, often unrecognized, manifestations of malnutrition are represented by various types of skin rash (associated with zinc dešciency or vitamins A and C dešciency), glossitis (ribo¬avin or pyridoxine dešciency), peripheral
31.1 Introduction .......................................................................................................................... 369 31.2 Pathophysiology of Malnutrition in End-Stage Liver Disease ............................................. 370 31.3 Specišc Nutrient Dešciencies in End-Stage Liver Disease and Associated Clinical
Features ................................................................................................................................. 371 31.3.1 Protein Calorie Malnutrition .................................................................................... 371 31.3.2 Vitamins ................................................................................................................... 371 31.3.3 Minerals .................................................................................................................... 372
31.4 Evaluation of Nutritional Status in End-Stage Liver Disease ............................................... 372 31.5 Treatment .............................................................................................................................. 374 31.6 Applications to Other Areas of Terminal or Palliative Care ................................................ 376 31.7 Practical Methods and Techniques ....................................................................................... 376 Key Points of Malnutrition in End-Stage Liver Disease ................................................................ 376 Ethical Issues ................................................................................................................................. 376 Summary Points ............................................................................................................................. 377 List of Abbreviation ....................................................................................................................... 377 References ...................................................................................................................................... 377
The diagnosis and assessment of malnutrition in ESLD is based on the specišc measurements of serum levels of micronutrients but more precise nutritional assessment requires the use of specialized testing. Anthropometry is based on the measurement of the mid-arm muscle circumference and triceps skinfold thickness. Bioelectrical impedance analysis compares the electrical conductivity through body fat and body water to determine fat and lean body mass. Nutritional therapy and support play a major role in the management of patients with ESLD and the principle behind the improvement of nutritional status is that it may improve liver function and hence survival.
