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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 16
| Issue : 1 | Page : 96-100 |
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Impact of pretransplant malnutrition on short-term clinical outcomes of liver transplantation - An exploratory study
Neha Bakshi1, Kalyani Singh1, Arvinder Singh Soin2
1 Department of Food and Nutrition, Lady Irwin College University of Delhi, India
2 Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| Date of Submission | 10-Dec-2020 |
| Date of Acceptance | 17-Oct-2021 |
| Date of Web Publication | 31-Mar-2022 |
Correspondence Address:
Dr. Neha Bakshi
University of Delhi, Delhi
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijot.ijot_153_20
Introduction: Malnutrition is highly prevalent among patients undergoing liver transplantation (LT) and can affect various clinical factors. The present study focuses on the impact of pretransplant malnutrition on various short-term outcomes of LT. Methods: Ninety LT recipients undergoing elective living donor LT were recruited in the study. Based on subjective global assessment (SGA), they were grouped as normal, moderate, and severely malnourished. Information regarding prognostic factors (Child-Turcotte-Pugh [CTP] and Model for End-Stage Liver Disease [MELD] scores), biochemical parameters (hemoglobin, TLC, platelets, bilirubin [T], serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, albumin, creatinine, and sodium), dietary intake, % weight loss, and short-term outcomes (hospital stay, intensive care unit days, blood unit usage during surgery, and dead and alive status after 1 year) were gathered. Results: The recipient evaluation showed that 54.4% of the patients were moderately malnourished and 27.8% of the patients were severely malnourished. The prognostic scores, CTP, and MELD significantly had higher scores in moderately and severely malnourished patients (P < 0.001 and P = 0.003). Among the biochemical parameters, hemoglobin, albumin, and sodium showed significantly lower levels in moderately and severely malnourished patients (P < 0.001, P = 0.02, and P = 0.01). The data also showed a significantly higher degree of ascites, % weight loss, and lower calorie intake among malnourished patients. A higher degree of malnutrition was associated with poor outcomes of LT; higher hospital stay (P = 0.014), packed red blood cell unit usage during surgery (P = 0.005), and deaths after 1 year of LT (P = 0.03). Conclusion: Pre-LT malnutrition by SGA was associated with poor short-term outcomes of LT with higher hospital stay and deaths. Hence, the present data emphasize the need for early nutrition intervention for improved surgery results.
Keywords: End-stage liver disease, liver transplantation, malnutrition, surgery outcomes
How to cite this article:
Bakshi N, Singh K, Soin AS. Impact of pretransplant malnutrition on short-term clinical outcomes of liver transplantation - An exploratory study. Indian J Transplant 2022;16:96-100 |
How to cite this URL:
Bakshi N, Singh K, Soin AS. Impact of pretransplant malnutrition on short-term clinical outcomes of liver transplantation - An exploratory study. Indian J Transplant [serial online] 2022 [cited 2023 Feb 5];16:96-100. Available from: https://www.ijtonline.in/text.asp?2022/16/1/96/342431 |
| Introduction | |  |
According to the Institute of Health Metrics and Evaluation, Global burden of deaths from cirrhosis and other liver diseases is 1.74% in all groups by the year 1990 which increased to 2.87% in the year 2019 among Indians. Hence, an increasing death from cirrhosis is seen in the Indian population over a period of time.[1]
Liver transplantation (LT) is the sole treatment for end-stage liver disease (ESLD) irrespective of the etiology.[2] LT in India is a relatively recent medical development for patients with liver failure after the year 1990. The prevalence of ESLD in India is not available.[2],[3] In India, 318 liver transplants were performed by the year 2007.[4]
Malnutrition is universally present in ESLD patients undergoing LT and has a multifactorial etiology.[5] Malnutrition has been associated with poor surgical outcomes and higher morbidity and mortality.[6],[7],[8] ESLD patients exhibit varied metabolic abnormalities of carbohydrate, lipid, and protein metabolism that increase the complications.[9] An absolute treatment program is incomplete without addressing all these nutrition-related issues both before and after LT.[5],[10],[11]
Despite the crucial role of nutrition in the prognosis of liver disease, the nutrition status assessment is challenging. It is difficult to accurately assess the nutrition status of cirrhotics because of complications such as fluid retention, hypoalbuminemia, and hypoproteinemia. Studies have shown subjective global assessment (SGA) as an independent predictor for outcomes of LT.[12],[13],[14] The European Society of Parenteral and Enteral Nutrition guidelines 2016 and 2019 recommend simple bedside methods such as SGA and/or anthropometry parameters to diagnose patients with poor nutritional status and bioelectrical impedance analysis can be used to quantify malnutrition despite certain limitations of these techniques in patients with ascites.[15],[16]
Malnutrition among ESLD patients undergoing LT has been associated with various prognostic, therapeutic factors, quality of life, and performance status.[17],[18] However, its associations with the outcome of LT have been under constant debate. Some studies have considered malnutrition as an independent factor for assessing the risk of poor outcomes.[10],[18]
The significance of nutrition status assessment in LT patients has been voiced by various researchers and its importance in the treatment of LT patients cannot be underrated.[9],[10],[11],[12],[13],[14],[15],[16] Hence, the present study aimed to assess the impact of the degree of malnutrition on short-term clinical outcomes of LT.
| Methods | | |
The present exploratory study was conducted at a tertiary level multispecialty hospital. All the adult patients awaiting LT were approached, and those who gave informed consent were recruited. Ethical clearance was obtained from the Lady Irwin College, Institutional Ethical Committee, and ninety patients undergoing elective living donor LT were recruited for the study using purposive sampling.
Data collection
Various tools were used to analyze and interpret the clinical parameters of the patients as described below:
Subjective global assessment
Nutrition assessment was performed by using SGA; it consists of five features: weight loss in the past 6 months (<5% – normal, 5%–10% – significant weight loss, and >10% – highly significant weight loss); dietary intake concerning patients' usual dietary pattern, the degree and duration of abnormal intake were also considered; the presence of significant gastrointestinal symptoms such as anorexia, nausea, vomiting, and diarrhea (persisting daily for more than 2 weeks); and the functional ability from bedridden to full ability to perform daily routine functions and metabolic stress due to the underlying disease state.[19],[20]
Clinical variable
Information regarding personal, medical history, and nutritional parameters (weight loss, dietary intake, mid-upper arm circumference [MUAC], and degree of ascites), was obtained from the patients' interviews and reports. The liver disease severity was analyzed by CTP Grades A, B, C, and MELD scores. The patients' stay in the hospital was considered in two categories: (i) intensive care unit (ICU) days and (ii) hospital days. After 1 year of transplant, the level of mortality was analyzed by the dead and alive profile of the patients. During the transplant, the blood product usage was taken into account, i.e., packed red blood cell (PRBC) units, fresh frozen plasma units, and cryo (cryoprecipitate) units. The patients' biochemical parameters were also recorded such as hemoglobin, TLC, platelets, bilirubin (T), serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, albumin, creatinine, and sodium.
Statistical analysis
All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 17.0 for Windows (SPSS Inc., Chicago, IL, USA).[21] Associations between categorical variables were evaluated through Chi-square tests. Normal variables were presented as means ± standard deviation and were analyzed by Kruskal–Wallis test adjusted with Bonferroni correction. The categorical data were analyzed using the Chi-square test with adjusted z-scores. An acceptable level of statistical significance was established a priori at P < 0.05.
Declaration of Patient consent
The patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity.
Ethics statement
Ethical Clearance was obtained from Institutional Ethics Committee, Lady Irwin College. Rgn. No. ECR/212/INDT/DL/2014.
| Results | | |
Background profile
Ninety patients were enrolled in the study. [Table 1] shows the demographic characteristics of the studied population. Patients were predominantly males with a mean age of 49.1 years. The data showed that 54.4% of the patients were CTP Grade C and 46.6% of the patients were having MELD scores <19. The two common indications for LT were cryptogenic liver disease (35.5%) and alcoholic liver disease (26.6%). The pre-LT biochemical parameters are depicted in [Table 1].
Nutritional profile
The data in [Table 2] revealed that 54.4% of the patients were suffering from moderate malnutrition and 27.8% were severely malnourished according to SGA scores. The majority of the patients were having an unintentional weight loss of >5% over 6 months. Patients' dietary intake was computed using 24-h dietary recall which showed that 45.5% of the patients were consuming 75%–50% of the recommended energy intake and 34.4% of the patients were having <50% of the recommended intake. The MUAC of the patients showed that 45.5% and 7.7% of the patients were moderately and severely malnourished, respectively. | Table 2: Nutritional profile of the patients before liver transplantation
Click here to view |
During the preliver transplant phase, 17.7% of the patients were suffering from tense ascites, 20% of the patients were severely nauseated, 21.1% of the patients were moderately active, and 7.7% were bedridden.
[Table 3] depicts prognostic scores such as CTP, and MELD significantly had higher scores in moderately and severely malnourished patients (P < 0.001 and P = 0.003). Among the biochemical parameters, hemoglobin, albumin, and sodium showed significantly lower levels in moderate and severe malnutrition (P < 0.001, P = 0.02, and P = 0.01) than normal patients. Furthermore, malnutrition was related to a higher number of hospital stay days (P = 0.014) and higher PRBC unit usage during surgery (P = 0.005). | Table 3: Clinical parameters of patients undergoing liver transplantation according to nutrition status
Click here to view |
[Table 4] (Chi-square analysis of categorical parameters) shows significant and adjusted residuals depicting which category had the largest difference. Analysis of nutrition status with dead and alive status of recipients after 1 year showed a significant association (P = 0.034). The data showed significantly lower death among normal nutrition status and a higher number of deaths among severely malnourished recipients. Furthermore, a significant association between nutrition status and ascites with adjusted residuals depicts the higher degree of ascites among malnourished recipients. The data also revealed significantly lower energy intake and higher weight loss among malnourished recipients.
| Discussion | | |
Nutrition management holds a crucial role in the treatment of liver failure both before and after the LT.[16] Previous studies exhibited a higher prevalence of malnutrition among patients undergoing LT and have identified malnutrition as an independent risk factor for poor outcomes of LT.[10],[11] Malnutrition has been associated with various clinical and nonclinical parameters before and after LT.[17],[22] There is a constant muddle regarding nutrition assessment tools for ESLD patients because of estimation errors due to ascites and albumin levels.[10],[13],[14],[23] Previous studies have considered SGA as a reliable and valid nutrition assessment tool and have been associated with various clinical and prognostic variables of patients undergoing LT.[14],[15],[16],[24] The present data demonstrated that 54.4% of the patients were moderately malnourished and 27.8% were severely malnourished by using SGA as a nutrition assessment tool.
Malnutrition is highly prevalent in ESLD patients irrespective of the varied etiology of liver disease.[10],[25] Previous studies have associated higher severity of liver disease with malnutrition.[26],[27],[28] The CTP and MELD scores are two prognostic tools for the severity of the liver disease; the present study also demonstrated significantly higher scores of CTP and MELD among malnourished patients. The present study also analyzed the association of various factors with the degree of malnutrition. The data demonstrated significantly lower hemoglobin and albumin levels among malnourished patients. Furthermore, malnourished patients experienced a significantly higher degree of ascites, lower % calorie intake, and higher % weight loss [Table 4]. Very few studies have focused on the association of various factors before LT which not only affect the nutrition status but also recipients' performance status and quality of life.[18]
Previous studies showed that malnutrition among pre-LT patients was associated with higher blood product usage such as PRBC units, cryoprecipitate units, and plasma during the surgery.[10],[12],[13] Similarly, the data in [Table 3] represent significantly higher blood product usage (PRBC units) in malnourished patients (P < 0.05) during the surgery. Preceding researches have demonstrated a strong relation of malnutrition with higher hospital stay and ICU days;[10],[24] the present study also depicted significantly higher hospital stay among malnourished patients though there was no significant relation between ICU days with the nutrition status of the patients before LT.
Attempts were made to analyze the association of malnutrition with death and survival status after 1 year of LT. The present data revealed significantly higher mortality among severely malnourished patients and lower deaths among normal patients [Table 4]. Various previous studies also showed an association of malnutrition with higher mortality among LT recipients.[24],[25]
The data showed that a significant proportion of liver transplant recipients were malnourished which is associated with mortality, the number of days in the hospital, and higher PRBC usage during surgery. Hence, planning early nutritional intervention can reduce the complications, and the surgery can be proved more cost-effective.
| Conclusion | | |
The present study concludes that a higher degree of malnutrition before LT is associated with poor short-term outcomes after the surgery. Nutrition is paramount and one of the unmapped aspects in the treatment of ESLD, hence proper nutrition therapy is the need of the hour for better LT outcomes.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | |
| 2. | Kumaran V. Liver transplantation in India. In: Textbook of Surgical Gastroenterology. Vol. 1 & 2. India: Jaypee Brothers Medical Publishers; 2016. p. 1172.  |
| 3. | Gopal PB, Kapoor D, Raya R, Subrahmanyam M, Juneja D, Sukanya B. Critical care issues in adult liver transplantation. Indian J Crit Care Med 2009;13:113-9. [ PUBMED] [Full text] |
| 4. | Kakodkar R, Soin A, Nundy S. Liver transplantation in India: Its evolution, problems and the way forward. Natl Med J India 2007;20:53-6. |
| 5. | Kerwin AJ, Nussbaum MS. Adjuvant nutrition management of patients with liver failure, including transplant. Surg Clin North Am 2011;91:565-78. |
| 6. | Lochs H, Plauth M. Liver cirrhosis: Rationale and modalities for nutritional support – The European society of parenteral and enteral nutrition consensus and beyond. Curr Opin Clin Nutr Metab Care 1999;2:345-9. |
| 7. | McCullough A, Bugianesi E. Protein-calorie malnutrition & the etiology of cirrhosis. Am J Gastroenterol 1997;92:734-8. |
| 8. | Prijatmoko D, Strauss BJ, Lambert JR, Sievert W, Stroud DB, Wahlqvist ML, et al. Early detection of protein depletion in alcoholic cirrhosis: Role of body composition analysis. Gastroenterology 1993;105:1839-45. |
| 9. | Merli M, Riggio O, Dally L. Does malnutrition affect survival in cirrhosis? PINC (Policentrica Italiana Nutrizione Cirrosi). Hepatology 1996;23:1041-6. |
| 10. | Bakshi N, Singh K. Nutrition assessment and its effect on various clinical variables among patients undergoing liver transplant. Hepatobiliary Surg Nutr 2016;5:358-71. |
| 11. | Bakshi N, Singh K. Nutrition management of acute postliver transplant recipients. Indian J Crit Care Med 2018;22:773-80. [ PUBMED] [Full text] |
| 12. | Stephenson GR, Moretti EW, El-Moalem H, Clavien PA, Tuttle-Newhall JE. Malnutrition in liver transplant patients: Preoperative subjective global assessment is predictive of outcome after liver transplantation. Transplantation 2001;72:666-70. |
| 13. | Mohanka R, Yadav SK, Bakshi N, Saraf N, Balachandran P, Saigal S, et al. Nutrition status using subjective global assessment (SGA) independently predicts outcome of patients waiting for living donor liver transplant. Liver Transpl 2014;20:S353-4. |
| 14. | Bakshi N, Singh K. Nutrition assessment in patients undergoing liver transplant. Indian J Crit Care Med 2014;18:672-81. [ PUBMED] [Full text] |
| 15. | Plauth M, Cabré E, Riggio O, Assis-Camilo M, Pirlich M, Kondrup J, et al. ESPEN guidelines on enteral nutrition: Liver disease. Clin Nutr 2006;25:285-94. |
| 16. | Plauth M, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, et al. ESPEN guideline on clinical nutrition in liver disease. Clin Nutr 2019;38:485-521. |
| 17. | Bakshi N, Singh K, Seth V, Jerath SJ. Impact of malnutrition on nutritional and non nutritional factors in end stage liver disease. Asian J Clin Nutr 2017;9:77-88. |
| 18. | Bakshi N, Singh K. Nutrition status and its impact on quality of life and performance status in end-stage liver disease. Indian J Transplant 2019;13:31-7. [Full text] |
| 19. | Keith JN. Bedside nutrition assessment past, present, and future: A review of the subjective global assessment. Nutr Clin Pract 2008;23:410-6. |
| 20. | Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr 1987;11:8-13. |
| 21. | SPSS. 17.0 Command Syntax Reference. Chicago, Illinois: SPSS Inc.,; 2009. |
| 22. | Merli M, Nicolini G, Angeloni S, Riggio O. Malnutrition is a risk factor in cirrhotic patients undergoing surgery. Nutrition 2002;18:978-86. |
| 23. | Figueiredo FA, Perez RM, Freitas MM, Kondo M. Comparison of three methods of nutritional assessment in liver cirrhosis: Subjective global assessment, traditional nutritional parameters, and body composition analysis. J Gastroenterol 2006;41:476-82. |
| 24. | Plauth M, Merli M, Kondrup J, Weimann A, Ferenci P, Müller MJ, et al. ESPEN guidelines for nutrition in liver disease and transplantation. Clin Nutr 1997;16:43-55. |
| 25. | Gunsar F, Raimondo ML, Jones S, Terreni N, Wong C, Patch D, et al. Nutritional status and prognosis in cirrhotic patients. Aliment Pharmacol Ther 2006;24:563-72. |
| 26. | Roongpisuthipong C, Sobhonslidsuk A, Nantiruj K, Songchitsomboon S. Nutritional assessment in various stages of liver cirrhosis. Nutrition 2001;17:761-5. |
| 27. | Ferreira LG, Anastácio LR, Lima AS, Correia MI. Assessment of nutritional status of patients waiting for liver transplantation. Clin Transplant 2011;25:248-54. |
| 28. | Bakshi N, Singh K. Diet and nutrition therapy in pre-liver transplant patients. Hepatoma Res 2016;2:207-15. |
[Table 1], [Table 2], [Table 3], [Table 4]
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