A Systematic Review of Medical Nutrition Therapy Guidelines for Liver Cirrhosis: Do We Agree?

Abstract

Background Nutrition can play a significant role in the management of liver cirrhosis and its complications. However, adherence to the clinical practice guidelines (CPGs) is essential for the practice of evidence‐based medicine and is considered as a health‐quality indicator. Methods A systematic search was conducted in scientific databases, and retrieved CPGs fulfilling the inclusion criteria were independently reviewed and appraised from 3 experienced researchers, based on the Appraisal of Guidelines for Research and Evaluation II instrument. Results A total of 13 relevant CPGs were retrieved, published by 7 associations/societies, focusing on the nutrition management (enteral nutrition and/or parenteral nutrition) on cirrhosis, decompensated cirrhosis, liver transplantation, and cirrhosis‐related complications. Most CPGs scored low in the stakeholder, rigor of development, and applicability domains. Half of the CPGs recognized the need for counseling patients with cirrhosis on nutrition‐related issues. Small meals spread throughout the day, including a late‐night snack, were suggested, with protein intake ranging between 1.2 and 1.5 g/kg of body weight. In ascites, Na restriction recommendation appeared unanimous. Conclusions Several shortcomings and bias were recognized in cirrhosis‐related medical nutrition therapy CPGs, indicating the need of improving CPG methodology.

Molecular Mechanism Contributing to Malnutrition and Sarcopenia in Patients with Liver Cirrhosis

“…Its functional integrity is essential for the supply and inter-organ trafficking of macronutrients (proteins, fat and carbohydrates) and their metabolism [ 12 , 13 ]. Nutrition is important in the management of liver cirrhosis and its complications [ 14 ]. Given the closely intertwined relation between the liver and nutrition, malnutrition is a very frequent feature in patients with liver cirrhosis [ 13 , 15 , 16 , 17 , 18 ].…”

“…According to the Global Leadership Initiative on Malnutrition (GLIM), the diagnosis of DRM requires a combination of phenotypical (unintentional loss of body weight, low body-mass index (BMI) or reduced muscle mass) and etiological criteria (reduced food intake/assimilation, inflammation or disease burden) [ 22 ]. DRM is very common among patients with liver cirrhosis occurring in at least 50% and up to 90% of patients and specifically high among patients with decompensated liver cirrhosis, while exceeding one-fifth of those with compensated liver cirrhosis [ 14 , 21 , 23 , 24 ]. This wide range is accounted for by the variation in methods used for the assessment of malnutrition [ 20 ].…”

Dietary Interventions in Liver Diseases: Focus on MAFLD and Cirrhosis

“…Adherence from the healthcare providers to nutritional recommendations remains suboptimal, and guidelines need to include pragmatic and feasible recommendations to improve adherence. In addition, and maybe most importantly, healthcare providers and patients need to be educated on malnutrition and its impact on the evolution of chronic liver diseases [122]. As for patients' awareness and empowerment, simple educational interventions, such as a simple nutrition education class followed by reinforcement phone calls, have been shown to be beneficial [78,[123][124][125].…”

Assessment of malnutrition in patient with liver cirrhosis and its association with dietary intake

“…Despite that malnutrition is often under recognized and under treated even though appropriate treatment can really improve outcomes. [8,9] There are wide diversities in the definition of malnutrition in cirrhosis, primarily because adult malnutrition is not well defined. [10] Thus a nutritional assessment in cirrhotic patients is needed.…”