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Nutritional Challenge in Advanced Chronic Liver Disease and Complications Related to Portal Hypertension

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A special issue of Nutrients (ISSN 2072-6643). This special issue belongs to the section "Clinical Nutrition".

Deadline for manuscript submissions: closed (20 July 2023) | Viewed by 20859

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Prof. Dr. Antonio Colecchia

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Guest Editor

Gastroenterology Unit, Department of Medical Specialities (CHIMOMO), University of Modena and Reggio Emilia, Via del Pozzo 71, 41124 Modena, Italy
Interests: liver diseases; gastrointestinal diseases; liver transplantation

Dr. Federico Ravaioli

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Guest Editor

Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
Interests: nutrition in liver diseases; cirrhosis; hepatocellular carcinoma; liver failure; liver surgery; gastrointestinal diseases; liver; hepatitis; hepatitis C; advanced statistical analysis

Special Issue Information

Dear Colleagues,

Clinical nutrition's key prognostic and therapeutic role in managing patients with chronic liver disease has recently been proposed and demonstrated. Various liver disease study associations (EASL, ESPEN, AGA, ...) have stressed to the global hepatology community the importance of research on nutritional and medical strategies along with etiological therapy in the management of any etiology and stage of liver disease. Furthermore, malnutrition and sarcopenia, even in obese patients with metabolic-associated fatty liver disease (so-called "sarcopenic obesity"), can worsen the prognosis of liver cirrhosis, reducing overall survival and negatively affecting the outcome of orthotopic liver transplantation.

This Special Issue, "Nutritional Challenge in Advanced Chronic Liver Disease and Complications Related to Portal Hypertension", aims to explore the latest and future challenges in nutritional investigation and insights that hepatologists should consider when addressing patients with advanced chronic liver disease (ACLD) based on liver disease etiology, the stage of liver cirrhosis and its portal hypertension development-related complications.

Topics of interest include, but are not limited to, the following:

Evaluation of the nutritional status and management of patients listed for orthotopic liver transplantation.
Role of bariatric surgery in obese patients listed for orthotopic liver transplantation before, during and after.
Branched-chain amino acids (BCAA) in compensated and decompensated advanced chronic liver disease (ACLD).
Commercial diets, meal replacements and newly intermittent fasting diets: applicability and evidence in patients with chronic liver diseases.
The role of vitamin D deficit and supplementation in chronic liver diseases.
Late evening snacks in patients with ACLD.

Original contributions, epidemiological studies, narrative and systematic reviews and meta-analyses are all welcome.

Dr. Antonio Colecchia
Dr. Federico Ravaioli
Guest Editors

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Keywords

sarcopenia
portal hypertension
BCAA
cirrhosis
MAFLD
NAFLD

Published Papers (9 papers)

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Research

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13 pages, 1804 KiB

Open AccessArticle

Redefining Nutritional Requirements in End-Stage Liver Disease: Towards a Personalized Approach

by Brooke Chapman, Darren Wong, Bethany Whitcher, Marie Sinclair, Paul Gow, Avik Majumdar and Adam Testro

Nutrients 2023, 15(22), 4770; https://doi.org/10.3390/nu15224770 - 13 Nov 2023

Viewed by 1346

Abstract

Malnutrition is ubiquitous in cirrhotic patients presenting for liver transplant (LT). Providing an appropriate energy prescription is fundamental to effective nutrition therapy. We aimed to compare measured energy expenditure (mEE) with predicted energy expenditure (pEE) in patients awaiting LT and determine clinical factors associated with mEE. In this prospective observational study, energy expenditure was measured by indirect calorimetry in 110 adult patients referred for LT and predicted by commonly utilized equations (Harris–Benedict, Schofield, and EASL guidelines). Nutritional status, anthropometry, muscle function, biochemical and clinical data were also collected. The median model for end-stage liver disease (MELD) was 19 (IQR 13, 25), and the majority were Child–Pugh B (51%) or C (37%). Malnutrition was evident in 85%. Median mEE by calorimetry was 1756 (1531, 2104) kcal/d and significantly higher than pEE as per Harris–Benedict 1480 (1322, 1722) kcal/d and Schofield 1474 (1349, 1723) kcal/d (both p < 0.001), but lower than EASL guidelines (35 kcal/kg) when an activity factor was applied to mEE; 2283 (1990, 2735) kcal/d versus 2590 (2178, 3010) kcal/d (p < 0.001). Hypermetabolism (mEE:pEE > 1.2) was evident in 48% of the cohort. Multivariate analysis found MELD, Child–Pugh class, diuretic use, and severe malnutrition to be independent predictors of hypermetabolism. A new liver-specific predictive model has been developed, showing superior agreement with mEE than common predictive equations. In conclusion, there is a poor correlation between mEE and pEE in patients awaiting LTs, and hypermetabolism is common. Relying on historical predictive equations in this patient population may result in significant under or over-feeding. A tailored energy prescription based on indirect calorimetry or a liver-specific predictive model is recommended for LT candidates. Full article

(This article belongs to the Special Issue Nutritional Challenge in Advanced Chronic Liver Disease and Complications Related to Portal Hypertension)

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13 pages, 518 KiB

Open AccessArticle

Association between Alcohol Consumption and Metabolic Dysfunction-Associated Steatotic Liver Disease Based on Alcohol Flushing Response in Men: The Korea National Health and Nutrition Examination Survey 2019–2021

by Dae Eon Kang and Si Nae Oh

Nutrients 2023, 15(18), 3901; https://doi.org/10.3390/nu15183901 - 07 Sep 2023

Viewed by 1129

Abstract

Metabolic dysfunction-associated steatotic liver disease (MASLD) is distinguished by the buildup of excessive liver fat unrelated to alcohol consumption. However, the role of alcohol consumption on disease progression is debatable. Recently, alcohol flushing syndrome in Asian populations has gained interest, and its role in the risk of developing MASLD is unknown. Therefore, in this cross-sectional study, we investigated the association between alcohol consumption and MASLD in Korean men, considering their alcohol flushing response and utilizing the lipid accumulation product (LAP) score. Data from the Korean National Health and Nutrition Examination Survey (2019–2021) were analyzed. Participants were categorized into non-or-infrequent drinkers and light-to-heavy drinkers and further sub-classified based on alcohol flushing response as non-flushers and flushers. Multivariate logistic regression analysis showed a significant association between alcohol consumption and MASLD risk in both non-flushers (aHR 1.90, 95% CI 1.51–2.40, p < 0.001) and flushers (aHR 2.35, 95% CI 1.94–2.84, p < 0.001) after adjusting for potential confounding factors such as age, exercise, smoking, body mass index, systolic blood pressure, total cholesterol, and fasting plasma glucose. There was a significant interaction between alcohol consumption and alcohol flushing response for MASLD risk (p for interaction < 0.001). These findings emphasize the importance of alcohol flushing as a potential indicator of MASLD risk in Korean men and highlight the need for further research to understand the underlying mechanisms and develop targeted preventive strategies. Full article

(This article belongs to the Special Issue Nutritional Challenge in Advanced Chronic Liver Disease and Complications Related to Portal Hypertension)

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16 pages, 1477 KiB

Open AccessArticle

A Low Daily Intake of Simple Sugars in the Diet Is Associated with Improved Liver Function in Cirrhotic Liver Transplant Candidates

by Simona Parisse, Sara Carnevale, Francesca Di Bartolomeo, Edoardo Poli, Francesca Miceli, Flaminia Ferri, Monica Mischitelli, Bianca Rocco, Quirino Lai, Pierleone Lucatelli, Mario Corona, Gianluca Mennini, Adriano De Santis, Massimo Rossi, Maurizio Muscaritoli, Alfredo Cantafora and Stefano Ginanni Corradini

Nutrients 2023, 15(7), 1575; https://doi.org/10.3390/nu15071575 - 24 Mar 2023

Cited by 1 | Viewed by 1299

Abstract

(1) Background: We investigated, for the first time, whether dietary simple sugar intake affects MELD score changes over time in a cohort of cirrhotic liver transplant candidates. (2) Methods: the MELD score, dietary habits using a 3-day food diary, and visceral adipose tissue index (VATI) measured with CT scan were assessed in 80 consecutive outpatient cirrhotic patients at baseline, after counseling to follow current nutritional guidelines. The MELD score was reassessed after six months and the DELTA-MELD was calculated as the MELD at the second assessment minus the MELD at baseline. (3) Results: Compared with the baseline, the MELD score of cirrhotic patients at the end of the study was decreased, stable, or increased in 36%, 8% and 56% of patients, respectively. In separate multiple linear regression models, DELTA-MELD was positively and independently correlated with the daily intake of simple sugars expressed in g/kg body weight (p = 0.01) or as a percentage of total caloric intake (p = 0.0004) and with the number of daily portions of fruit, added sugar, jam, and honey (p = 0.003). These associations were present almost exclusively in patients with VATI above the median value. (4) Conclusions: In cirrhotic patients with high amounts of visceral adipose tissue the consumption of simple sugars and fructose should be limited to improve their clinical outcome. Full article

(This article belongs to the Special Issue Nutritional Challenge in Advanced Chronic Liver Disease and Complications Related to Portal Hypertension)

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14 pages, 288 KiB

Open AccessArticle

Effects of COVID-19 Pandemic on Metabolic Status and Psychological Correlates of a Cohort of Italian NAFLD Outpatients

by Silvia Ferri, Bernardo Stefanini, Marta Minguzzi, Simona Leoni, Roberta Capelli, Alice Secomandi, Rusi Chen, Chiara Abbati, Ernestina Santangeli, Katia Mattarozzi and Piscaglia Fabio

Nutrients 2023, 15(6), 1445; https://doi.org/10.3390/nu15061445 - 16 Mar 2023

Cited by 1 | Viewed by 1244

Abstract

Non-alcoholic fatty liver disease (NAFLD) is a potentially progressive condition characterized by the presence of fat in more than 5% of hepatocytes, representing the hepatic expression of metabolic syndrome (MetS). A reduction of at least 5–7% in initial body weight improves the metabolic profile underlying NAFLD. The aim of our study was to evaluate the effects of the COVID-19 lockdown on a cohort of non-advanced NAFLD Italian outpatients. We identified 43 patients with 3 available time point visits in our center: first visit (T0) when behavioral indications aimed at controlling MetS were provided, a pre-COVID visit (T1) and a post-COVID visit (T2). During the lockdown, an online compilation of validated psychological tests (SRQ-20, EQ5D, SF-12 and STAI) and a specifically formulated questionnaire for NAFLD was presented to our cohort and completed by 14 consenting patients. Patients who had lost more than 5% of the initial weight at T1 (9 subjects, 21%) maintained the results even at T2, with an overall reduction in BMI and liver stiffness; patients who had not lost the desired weight at T1 (34 subjects, 79%) displayed a further increase in BMI and visceral adiposity at T2. Of interest is that patients in the latter group reported signs of psychological suffering. Our data demonstrated that the setting of good counseling was effective in controlling the metabolic disorder underlying NAFLD in our cohort of outpatients. Given the need for patients to play an active role in the behavioral therapy for NAFLD, we advocate that a multidisciplinary approach be adopted, including a psychological support to obtain the best results over time. Full article

(This article belongs to the Special Issue Nutritional Challenge in Advanced Chronic Liver Disease and Complications Related to Portal Hypertension)

Review

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13 pages, 1752 KiB

Open AccessReview

Use of Branched-Chain Amino Acids as a Potential Treatment for Improving Nutrition-Related Outcomes in Advanced Chronic Liver Disease

by Santo Colosimo, Simona Bertoli and Francesca Saffioti

Nutrients 2023, 15(19), 4190; https://doi.org/10.3390/nu15194190 - 28 Sep 2023

Cited by 1 | Viewed by 1755

Abstract

Advanced chronic liver disease (ACLD) represents a complex and multifactorial clinical entity characterized by liver dysfunction and associated complications. In recent years, the significance of nutritional status in ACLD prognosis has gained considerable attention. This review article delves into the multifactorial pathogenesis of malnutrition in ACLD and its profound consequences for health outcomes. We explore the clinical implications of secondary sarcopenia in ACLD and highlight the critical relevance of frailty in both decompensated and compensated ACLD. A specific focus of this review revolves around branched-chain amino acids (BCAAs) and their pivotal role in managing liver disease. We dissect the intricate relationship between low Fischer’s ratio and BCAA metabolism in ACLD, shedding light on the molecular mechanisms involved. Furthermore, we critically evaluate the existing evidence regarding the effects of BCAA supplementation on outcomes in ACLD patients, examining their potential to ameliorate the nutritional deficiencies and associated complications in this population. Full article

(This article belongs to the Special Issue Nutritional Challenge in Advanced Chronic Liver Disease and Complications Related to Portal Hypertension)

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14 pages, 2246 KiB

Open AccessReview

Unlocking the Power of Late-Evening Snacks: Practical Ready-to-Prescribe Chart Menu for Patients with Cirrhosis

by Laura Leoni, Filippo Valoriani, Riccardo Barbieri, Martina Pambianco, Martina Vinciguerra, Chiara Sicuro, Antonio Colecchia, Renata Menozzi and Federico Ravaioli

Nutrients 2023, 15(15), 3471; https://doi.org/10.3390/nu15153471 - 05 Aug 2023

Cited by 3 | Viewed by 2976

Abstract

The efficacy of the late-evening snack (LES) has been extensively studied due to the impact of the longest intermeal duration occurring at night in patients with cirrhosis. While actual clinical guidelines on nutrition in chronic liver disease recommend an LES, no specific nutritional compositions have been reported by the European Association for the Study of the Liver (EASL) and the European Society for Clinical Nutrition and Metabolism (ESPEN). Late-evening snacks vary greatly among studies, including natural foods and/or nutritional supplements, yet oral supplements still need to fully meet the LES’s nutritional composition. In addition, many hepatologists need to gain experience in nutritional approaches and have access to registered dieticians who can help them manage patients with liver disease. Therefore, this review study aims to summarise evidence regarding using LESs and the mechanisms behind long starvation in patients with cirrhosis. It also provides a practical nutritional guide with several LES options based on common natural foods tailored to special patients’ nutritional requirements and geographical backgrounds. In preventing accelerated starvation and related protein malnutrition and sarcopenia in patients with cirrhosis, the nutritional composition of LESs is essential. The proper and straightforward application of the LES’s rational nutrition is an advantage to cirrhotic patients and should be carried out by healthcare professionals to enhance the overall liver function and nutritional status of patients with cirrhosis. Full article

(This article belongs to the Special Issue Nutritional Challenge in Advanced Chronic Liver Disease and Complications Related to Portal Hypertension)

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30 pages, 1582 KiB

Open AccessReview

From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients

by Federico Ravaioli, Nicola De Maria, Lorenza Di Marco, Alessandra Pivetti, Riccardo Casciola, Carlo Ceraso, Gabriella Frassanito, Martina Pambianco, Maddalena Pecchini, Chiara Sicuro, Laura Leoni, Stefano Di Sandro, Paolo Magistri, Renata Menozzi, Fabrizio Di Benedetto and Antonio Colecchia

Nutrients 2023, 15(12), 2778; https://doi.org/10.3390/nu15122778 - 16 Jun 2023

Cited by 5 | Viewed by 1925

Abstract

Liver transplantation (LT) is a complex surgical procedure requiring thorough pre- and post-operative planning and care. The nutritional status of the patient before, during, and after LT is crucial to surgical success and long-term prognosis. This review aims to assess nutritional status assessment and management before, during, and after LT, with a focus on patients who have undergone bariatric surgery. We performed a comprehensive topic search on MEDLINE, Ovid, In-Process, Cochrane Library, EMBASE, and PubMed up to March 2023. It identifies key factors influencing the nutritional status of liver transplant patients, such as pre-existing malnutrition, the type and severity of liver disease, comorbidities, and immunosuppressive medications. The review highlights the importance of pre-operative nutritional assessment and intervention, close nutritional status monitoring, individualised nutrition care plans, and ongoing nutritional support and monitoring after LT. The review concludes by examining the effect of bariatric surgery on the nutritional status of liver transplant recipients. The review offers valuable insights into the challenges and opportunities for optimising nutritional status before, during, and after LT. Full article

(This article belongs to the Special Issue Nutritional Challenge in Advanced Chronic Liver Disease and Complications Related to Portal Hypertension)

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10 pages, 991 KiB

Open AccessReview

The Impact of Transjugular Intrahepatic Portosystemic Shunt on Nutrition in Liver Cirrhosis Patients: A Systematic Review

by Jakub Gazda, Simone Di Cola, Lucia Lapenna, Saniya Khan and Manuela Merli

Nutrients 2023, 15(7), 1617; https://doi.org/10.3390/nu15071617 - 27 Mar 2023

Cited by 5 | Viewed by 1805

Abstract

Background and Aims: Liver cirrhosis leads to clinically significant portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) has been shown to effectively reduce the degree of portal hypertension and treat its complications. However, poor nutritional status has been shown to be associated with hepatic encephalopathy, acute on chronic liver failure, and mortality following TIPS placement. The purpose of this systematic review is to create another perspective and evaluate the effect of TIPS placement on the nutritional status of patients with liver cirrhosis. Methods: A comprehensive search of four major electronic databases was conducted to identify studies that assessed the nutritional status of cirrhotic patients before and after TIPS placement. The risk of bias was evaluated using ROBINS-I guidelines. Results: Fifteen studies were analyzed in this review. The results indicate that among the 11 studies that evaluated changes in ascites-free weight and body mass index or body cell mass, 10 reported an improvement in one or more measures. Furthermore, all seven studies that evaluated changes in muscle mass demonstrated an increase in muscle mass. Among the four studies that evaluated subcutaneous fat tissue, three showed a significant expansion, while two out of three studies evaluating visceral fat tissue reported a significant reduction. Conclusions: The results of this systematic review suggest that TIPS placement is associated with improvement in the nutritional status of cirrhotic patients, indicated by an increase in ascites-free weight, body mass index, and muscle mass. Additionally, TIPS placement leads to a shift in the distribution of fat mass, with a preference for subcutaneous over visceral adipose tissue. Notably, sarcopenic patients seem to benefit the most from TIPS placement in terms of nutritional status. Full article

(This article belongs to the Special Issue Nutritional Challenge in Advanced Chronic Liver Disease and Complications Related to Portal Hypertension)

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14 pages, 858 KiB

Open AccessReview

Creatine Supplementation to Improve Sarcopenia in Chronic Liver Disease: Facts and Perspectives

by Riccardo Casciola, Laura Leoni, Biagio Cuffari, Maddalena Pecchini, Renata Menozzi, Antonio Colecchia and Federico Ravaioli

Nutrients 2023, 15(4), 863; https://doi.org/10.3390/nu15040863 - 08 Feb 2023

Cited by 5 | Viewed by 6494

Abstract

Creatine supplementation has been one of the most studied and useful ergogenic nutritional support for athletes to improve performance, strength, and muscular mass. Over time creatine has shown beneficial effects in several human disease conditions. This review aims to summarise the current evidence for creatine supplementation in advanced chronic liver disease and its complications, primarily in sarcopenic cirrhotic patients, because this condition is known to be associated with poor prognosis and outcomes. Although creatine supplementation in chronic liver disease seems to be barely investigated and not studied in human patients, its potential efficacy on chronic liver disease is indirectly highlighted in animal models of non-alcoholic fatty liver disease, bringing beneficial effects in the fatty liver. Similarly, encephalopathy and fatigue seem to have beneficial effects. Creatine supplementation has demonstrated effects in sarcopenia in the elderly with and without resistance training suggesting a potential role in improving this condition in patients with advanced chronic liver disease. Creatine supplementation could address several critical points of chronic liver disease and its complications. Further studies are needed to support the clinical burden of this hypothesis. Full article

(This article belongs to the Special Issue Nutritional Challenge in Advanced Chronic Liver Disease and Complications Related to Portal Hypertension)

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