A narrative review of nutritional abnormalities, complications, and optimization in the cirrhotic patient

Abstract

Objective: The purpose of this manuscript is to identify the pathophysiology of the metabolic abnormalities observed in cirrhosis and to uncover associations, if any, to its complications, such as sarcopenia and hepatic encephalopathy (HE).Background: Liver dysfunction in cirrhosis is known to be a precipitating factor in the disruption of many physiological pathways, specifically nutrient metabolism. As a result, affected patients are highly susceptible to derangements of processes affecting multiple classes of macro-and micronutrients, including proteins, carbohydrates, electrolytes, vitamins, and minerals. These disruptions are thought to be contributory to the pathogenesis of known complications of cirrhosis.Methods: Literature research of relevant topics was conducted for the above stated objective; sources were limited to articles from peer-reviewed journals published within the last 30 years.Conclusions: This research established that there is positive correlation between nutrient derangements and the increased risk of complications of cirrhosis, which themselves carry significant morbidity and mortality risk. It also established that some nutrient and electrolyte abnormalities are independent indicators of prognosis and adverse outcomes, such as mortality. This also highlights the importance of comprehension of anomalous metabolism and its complications as it necessitates serious consideration in clinical care. In addition to medical management, cirrhotic patients also require ancillary assessment, such as comprehensive nutritional evaluation, to identify and treat reversible nutritional derangements. This consideration provides the best opportunity to achieve maximal health outcomes in the cirrhotic patient population.

Sarcopenia in the Cirrhotic Patient: Current Knowledge and Future Directions

“…Hepatic encephalopathy -Hepatic encephalopathy is a spectrum of neurocognitive dysfunction that results from acute or chronic liver disease; patients may be asymptomatic or demonstrate symptoms ranging from confusion to coma [14] . Nitrogen in the form of ammonia is metabolized to urea in the liver; urea may then be excreted into urine as waste.…”

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

“…Recently, since the documented clinical relevance of nutrition in the evolution of cirrhosis, international scientific societies have oriented their efforts toward the identification of common dietary and lifestyle recommendations to ameliorate the nutritional status and dietary habits of patients affected by chronic liver diseases and cirrhosis [ 7 , 11 , 12 , 13 ]. However, considering the guidelines of international scientific societies and also the recommendations recently published outside them, the consumption of oral carbohydrates by cirrhotic patients is little addressed, with only a few exceptions and some conflicting points that can be summarized as follows: (a) carbohydrates should account for different percentages of caloric intake ranging from 50–60% to 45–75% [ 13 , 14 , 15 ]; (b) in overweight/obese patients, a reduction in the intake of carbohydrates and fat is recommended as an indirect consequence of the recommendation to follow a low-calorie and high-protein diet [ 7 , 11 , 13 , 16 , 17 ]; (c) the possibility or the recommendation of using carbohydrates, according to some authors preferably complex carbohydrates, in evening snacks that play a beneficial role in limiting the duration of fasting periods [ 11 , 12 , 13 , 16 ]; (d) the recommendation of eating plenty of fruits and vegetables contained in the EASL guidelines [ 7 ]; (e) in contrast with the latter recommendation, preferring complex carbohydrates and not allowing simple sugars to exceed 10–15% of the total caloric intake [ 13 , 15 ]. This last recommendation, which is not contained in the recent nutritional guidelines of international scientific societies for cirrhotic patients, is derived from the guidelines of the World Health Organization on sugar consumption in the general population, which recommend a consumption lower than 10% of total caloric intake [ 18 ].…”

Cirrhosis and Sarcopenia

“…This is marked by a chronic state of accelerated starvation characterized by inadequate dietary intake, malabsorption, and metabolic disturbances resulting in protein and nutrient deficiencies, fluid imbalance, and electrolyte abnormalities. 3 4…”

“…5 Emerging in recent literature is the prevalence of sarcopenia and the effect it has on the morbidity and mortality of cirrhotic patients. 1 2 3 4 5 6 7 8 9 10 Sarcopenia, in its most simple form, is a muscle wasting syndrome characterized by loss of muscle mass. This review outlines the epidemiology, pathogenesis, assessment, and clinical impact of sarcopenia in cirrhosis.…”

“…This is marked by a chronic state of accelerated starvation characterized by inadequate dietary intake, malabsorption, and metabolic disturbances resulting in protein and nutrient deficiencies, fluid imbalance, and electrolyte abnormalities. 3,4 Cirrhotic patients are at an increased risk for developing frailty, renal dysfunction, infections, and malignancy. Decompensated cirrhosis is characterized by variceal bleeding, refractory ascites, and hepatic encephalopathy (HE).…”