Nutrition guide for CIRRHOSIS patients

Mahitab Hany, BS Pharm, PGDipClinPharm, PGDipClinNutrition, BCNSP

As a nutrition support pharmacist, you will be asked more about the recent recommendations to ensure proper nutrition in patients with cirrhosis. Malnutrition is a significant concern for patients with cirrhosis, affecting up to 20% of those with compensated cirrhosis and 50% of those with decompensated cirrhosis. A state of malnutrition in cirrhosis has also been defined as a BMI ≤ 22 kg/m2 with no ascites, ≤ 23 kg/m2 with mild ascites, or ≤ 25 kg/m2 with tense ascites. In order to address the issue of edema and ascites leading to inaccurately elevated BMI measurements, adjustments have been devised to mitigate their impact. These adjustments involve subtracting a specific percentage from the measured weight based on the severity of ascites.

For mild ascites, 5% is subtracted, for moderate ascites, 10% is subtracted, and for severe ascites, 15% is subtracted. Furthermore, an additional 5% is subtracted in cases where pedal edema is present.

NPS-adv

Key factors contributing to malnutrition in cirrhosis include decreased oral intake, malabsorption, and reduced synthesis of bile acids. Let's explore evidence-based recommendations to address this issue. A comprehensive nutritional assessment is crucial for effective management of malnutrition. It involves subjective global assessment (SGA), anthropometric (height, weight, mid-arm circumference, etc) and biochemical measurements (albumin, CBC, transferrin, liver function tests, glucose, cholesterol, etc). The SGA is a questionnaire with both a history and a physical examination component, which can be used to classify patients into 1 of 3 stages: well nourished (Stage A), moderately malnourished (Stage B), or severely malnourished (Stage C).

For malnourished cirrhosis patients, the goal is to consume 35-40 kcal/kg/day (adjusted for ascites) to promote anabolism.
Protein intake should be 1.2-1.5 g/kg/day, while carbohydrates should contribute to 50-70% of daily calories and fats to 10-20%.
Supplementation with oral branched-chain amino acids at a dose of 4 g/day has been found to improve albumin and protein synthesis, while reducing the risk of hepatic decompensation. Studies suggest that replacing meat protein with vegetable protein can be advantageous for cirrhosis patients. Vegetable protein, with lower sulfur content and higher levels of arginine and ornithine, aids in ammonia disposal.
Recommend 2 g sodium-restricted diet, it's effective when combined with diuretic therapy for controlling fluid overload.
To address zinc deficiency, supplementation with 150-175 mg/day has shown benefits in reducing ammonia levels.
It is recommended that all patients take 2,000 IU of vitamin D daily. Deficient patients may require 50,000 IU weekly for 8-12 weeks to achieve a target 25-hydroxyvitamin D level of at least 30 ng/mL.
Interestingly, coffee consumption has been associated with a decreased risk of cirrhosis progression, lower mortality rate, and a lower incidence of hepatocellular carcinoma.

References

Cheung K, Lee SS, Raman M. Prevalence and mechanisms of malnutrition in patients with advanced liver disease, and nutrition management strategies. Clin Gastroenterol Hepatol. 2012;10(2):117-25.
Moctezuma-Velázquez C, García-Juárez I, Soto-Solís R, et al. Nutritional assessment and treatment of patients with liver cirrhosis. Nutrition. 2013;29(11-12):1279-85.
McClain CJ. Nutrition in Patients With Cirrhosis. Gastroenterol Hepatol (N Y). 2016;12(8):507-510.
Katayama K, Saito M, Kawaguchi T, et al. Effect of zinc on liver cirrhosis with hyperammonemia: a preliminary randomized, placebo-controlled double-blind trial. Nutrition. 2014;30(11-12):1409-14.
Saab S, Mallam D, Cox GA, et al. Impact of coffee on liver diseases: a systematic review. Liver Int. 2014;34(4):495-504.