At THE LIVER MEETING 2017
WASHINGTON (FRONTLINE MEDICAL NEWS) – Efforts to improve nutritional status prior to transplant may lead to improved patient outcomes and economic benefits after orthotopic liver transplant.
Clinicians at Austin Health, a tertiary health center in Melbourne, reviewed prospectively acquired data on 390 adult patients who underwent orthotopic liver transplant at their institution between January 2009 and June 2016, according to Brooke Chapman, a dietitian on the center’s transplant team.
Nutritional status was assessed by subjective global assessment and categorized as well nourished, mildly to moderately malnourished, or severely malnourished. Functional muscle assessment was done by via hand-grip strength test and 6-minute walk test.
“Hand-grip strength test is a functional measure of upper-body strength,” Ms. Chapman said at the annual meeting of the American Association for the Study of Liver Diseases. “It’s quick and cheap and reliable but importantly, it does respond quite readily to changes in nutritional intake and nutrition status.”
Assessments were made as patients were wait listed for liver transplant. Hand-grip strength and subjective global assessment were repeated at the time of transplant.
Patients with fulminant liver failure and those requiring retransplantation were excluded from the final analysis, leaving 321 patients in the cohort. More than two-thirds (69%) were men and the median age was 52 years old. About half of patients had a diagnosis of hepatocellular carcinoma or hepatitis C infection. The median MELD (Model for Endstage Liver Disease) score was 18, with a range of 6-40, and the median time on the wait list was 140 days.
We saw a “high prevalence of malnutrition in patients undergoing liver transplant and the deterioration in nutritional status despite our best efforts while they are on the waiting list,” Ms. Chapman said.
At baseline, two-thirds of patients were malnourished – either mildly to moderately or severely; by transplantation, 77% were malnourished.
“At assessment, we are prescribing and educating patients on a high-calorie, high-protein diet initially, and we give oral nutrition support therapies,” she said. “We really try to get them to improve oral intake, but for patients who do require more aggressive intervention, we will feed them via nasogastric tube.”
Just over half (55%) of patients fell below the cutoff for sarcopenia on the hand-grip test at baseline and at transplant. More than a quarter of patients (27%) were not able to complete the 6-minute walk test.
“On univariate analysis, we saw malnutrition to be strongly associated with increased ICU and hospital length of stay,” Ms. Chapman noted. Severely malnourished patients spent significantly more time in the ICU than did well-nourished patients – a mean 147 hours vs. 89 hours (P = .001). Mean length of stay also was significantly longer at 40 days vs. 16 days (P = .003).
There was also an increased incidence of infection in severely malnourished patients as compared with well-nourished patients – 55.2% vs. 33.8%, she said.
“Aggressive strategies to combat malnutrition and deconditioning in the pretransplant period may lead to improved outcomes after transplant,” Ms. Chapman concluded.
The study was funded by Austin Health. Ms. Chapman declared no relevant conflicts of interest.
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