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Nutritional Assessment and Malnutrition in Patients With Cirrhosis

Chaney, Amanda APRN, DNP; Rawal, Bhupendra MS; Harnois, Denise DO; Keaveny, Andrew MD

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doi: 10.1097/SGA.0000000000000447
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Abstract

Malnutrition is the most common complication of advanced liver disease, occurring in 50%–90% of patients with cirrhosis (Johnson, Overgard, Cohen, & DiBaise, 2013). Delayed wound healing, compromised respiratory and immune function, longer hospital stays, increased healthcare costs, and increased risk of other complications of liver disease such as ascites and hepatorenal syndrome have all been associated with malnutrition in patients with cirrhosis (Johnson et al., 2013; Maharshi, Sharma, & Srivastava, 2015; Ney et al., 2015). Fluid balance and muscle mass are altered after years of illness, with substantial loss of muscle mass (sarcopenia) and adipose tissue (Montano-Loza, 2014). Additionally, a correlation has been reported between sarcopenia and pre-, peri-, and posttransplant mortality in patients with cirrhosis (Masuda et al., 2013).

Background

Several specific laboratory abnormalities have been associated with malnutrition including serum transferrin, fat-soluble vitamin, albumin, total cholesterol, total lymphocyte count, and zinc levels (Johnson et al., 2013; Montano-Loza, 2014). Fat-soluble vitamin deficiencies are common in patients with chronic liver disease, as the normal absorptive pathways are disrupted (Montano-Loza, 2014). Patients with cirrhosis frequently gain weight from fluid retention and ascites, which results in a higher body weight and body mass index (BMI) which in turn do not reflect an accurate nutritional state (Montano-Loza, 2014). The consequences of vitamin deficiencies include night blindness, bone disease, and post–liver transplant (LT) reperfusion injury (Venu, Martin, Saeian, & Gawrieh, 2013). Finkelmeier et al. (2014) reported an association between severe vitamin 25(OH)D3 deficiency and worse outcomes in patients with hepatocellular carcinoma. Low protein intake in patients with cirrhosis has been associated with malnutrition and a higher rate of mortality (Ney et al., 2015).

Malnutrition is often underdiagnosed in patients with cirrhosis and treatment may therefore be delayed (Montano-Loza, 2014). The subjective global assessment (SGA) is a tool that is frequently used by providers to evaluate for malnutrition. This assessment uses specific dietary history, weight loss, and physical examination findings (edema, ascites, muscle wasting, and presence of subcutaneous fat) to determine malnutrition risk (“Subjective Global Assessment: A highly reliable nutritional assessment tool,” 2012). This tool is acceptable, valid, and reliable when compared with other nutrition-screening tools (Bauer, Capra, & Ferguson, 2002; Vigano et al., 2014). According to the “Evaluation for Liver Transplantation in Adults: 2013 Practice Guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation,” cases of severe muscle wasting may be overlooked because of the presence of ascites or obesity (Martin, DiMartini, Feng, Brown, & Fallon, 2014). Nutrition assessment by a skilled nutrition specialist is a mandatory component of the LT evaluation not only to recognize malnutrition but also to provide accurate education regarding proper protein intake (Martin et al., 2014). The SGA tool takes into account the patient's dietary history, as well as ascites and fluid retention issues that are commonly a problem for patients with end-stage liver disease.

The aim of this retrospective review was to determine the prevalence of malnutrition in patients with cirrhosis (those listed for LT). We also sought to identify patient outcomes of malnutrition and cirrhosis (i.e., hospitalizations up to and including that for LT, length of hospital stay [LOS], and frequency of enteral nutritional support).

Methods

This study was a retrospective chart review approved by the Mayo Clinic Institutional Review Board, #13-007778. Inclusion criteria were patients who were listed for their first LT from January 1, 2013, to September 30, 2013. Exclusion criteria included patients who were listed for multiple organ transplants and those who had received a prior LT. Demographic data included patients' race and gender, height, current weight, BMI, and degree of malnutrition if documented by a provider (classified as mild, moderate, and severe) at the initial evaluation (IE). Laboratory data at the IE for transplant included serum albumin, prealbumin, transferrin, total cholesterol, and zinc levels as well as total lymphocyte count and vitamin A, D, and E (fat-soluble vitamins) levels.

All patients undergoing an LT evaluation completed a nutrition education class with a nutrition specialist, who was a licensed dietician/registered dietician (LD/RD) (see Table 1). This specialist assigned an SGA score, categorized as well-nourished (A), mild–moderate or at risk of malnutrition (B), or severe malnutrition (C) (“Subjective Global Assessment: A highly reliable nutritional assessment tool,” 2012). Several factors are considered in deriving an SGA score, including loss of subcutaneous fat and peripheral or sacral edema; muscle wasting, grading it as normal or mildly, moderately, or severely decreased; and patient history, including weight loss in the past 6 months (<5% is small, 5%–10% is potentially significant, and >10% is significant) (“Subjective Global Assessment: A highly reliable nutritional assessment tool,” 2012). In addition, the patient's intake and presence of gastrointestinal symptoms including anorexia, nausea, vomiting, and diarrhea are reviewed (“Subjective Global Assessment: A highly reliable nutritional assessment tool,” 2012).

TABLE 1. - Standard of Care for Liver Transplant Evaluation—Nutrition
Initial visit with a physician (hepatologist, gastroenterology fellow)
Laboratory studies/consults ordered
Nutrition visit with nutrition education and assessment (SGA score documented at this time by LD/RD)
All studies ordered within 1–2 weeks of initial visit with a physician
Return visit with physician All studies, laboratory test results consults are reviewed with patient to determine candidacy for LT
Note. LD/RD = licensed dietitian/registered dietitian; LT = liver transplant; SGA = subjective global assessment score.

Once the information is obtained, the patient is given a grade of well-nourished (SGA A), moderately malnourished or suspected of being malnourished (SGA B), or severely malnourished (SGA C) (“Subjective Global Assessment: A highly reliable nutritional assessment tool,” 2012). If the specialist believed that the patients had or was at risk for a nutrition issue, they were sent for an individualized nutrition evaluation and development of a treatment plan. We recorded the timing of nutrition consults, follow-up assessments, and the frequency and type of enteral nutritional support that was prescribed. The indication for any hospitalization and hospital LOS after the IE were noted. All patients had an SGA score assigned by a member of the nutrition team at the time of LT. It was also documented if the physicians performing the IE stated “malnutrition” as a part of their documentation.

Theory/Statistical Analysis

The numeric variables were summarized with the sample median (range), and categorical variables were summarized with number (percentage). Fisher exact test or Wilcoxon rank sum test was used for two group comparisons. The McNemar's test for paired samples was used to compare SGA measured at different nutrition assessment visits. A multivariable logistic regression model was used to assess an association of SGA at initial nutrition visit to the patients' demographic and clinical characteristics (the details are described in Tables 2 and 3). The odds ratio (OR) and 95% confidence intervals were reported. A natural log transformation of the total hospital LOS (days) was performed to make them closely normally distributed.

TABLE 2. - Clinical, Laboratory, Vitamin Levels, and Admission Information for Overall Sample and According to the Subjective Global Assessment at Initial Nutrition Visita
Variables Overall Sample (N = 134) SGA at Initial Nutrition: Well-Nourished (n = 62) SGA at Initial Nutrition: Moderately or Severely Malnourished (n = 67) p
Age at medical evaluation (years) 60 (29–73) 61 (29–73) 59 (38–73) .38
Gender (male) 98 (73%) 51 (82%) 43 (64%) .029
Race (White) 104 (78%) 49 (79%) 52 (78%) 1.00
BMI 27.9 (19.4–44.2) 27.4 (20.1–39.0) 28.5 (19.4–44.2) .53
Primary diagnosis
Viral (hepatitis B, C)
Alcohol
Cryptogenic/NASH
Other

60 (45%)
26 (19%)
24 (18%)
24 (18%)

32 (52%)
11 (18%)
9 (15%)
10 (16%)

26 (39%)
13 (19%)
15 (22%)
13 (19%)
.49
Total cholesterol 135 (36–370) 139 (61–297) 131.5 (36–370)
Total cholesterol categories
<160
≥160

95 (73.1%)
35 (26.9%)

41 (68.3%)
19 (31.7%)

51 (77.3%)
15 (22.7%)
.32
Total lymphocyte (×1,000) 900 (200–3,600) 900 (300–2,400) 900 (200–3,500)
Total lymphocyte categories
<1,500
≥1,500

111 (82.8%)
23 (17.2%)

52 (83.9%)
10 (16.1%)

56 (83.6%)
11 (16.4%)
1.00
Transferrin 204 (73–609) 225 (109–523) 170 (73–609)
Transferrin categories
<200
≥200

63 (48.8%)
66 (51.2%)

24 (40.0%)
36 (60.0%)

38 (58.5%)
27 (41.5%)
.049
Albumin 3.4 (1.7–5.1) 3.6 (2.0–5.1) 3.2 (1.7–4.7)
Albumin categories
<3.4
≥3.4

64 (47.8%)
70 (52.2%)

22 (35.5%)
40 (64.5%)

42 (62.7%)
25 (37.3%)
.003
Zinc level 0.50 (0.25–1.84) 0.55 (0.28–1.15) 0.45 (0.25–1.84)
Zinc-level categories
<0.66
≥0.66

102 (77.9%)
29 (22.1%)

42 (68.9%)
19 (31.1%)

56 (84.9%)
10 (15.1%)
.036
Vitamin A level 12.2 (1.9–82.2) 15.7 (2.9–82.2) 10.8 (1.9–73.8)
Vitamin A–level categories
<32.5
≥32.5

112 (84.9%)
20 (15.1%)

49 (80.3%)
12 (19.7%)

60 (89.6%)
7 (10.4%)
.21
Vitamin D level 17.2 (5.9–81.9) 20.5 (7.2–62.2) 15.5 (5.9–81.9)
Vitamin D–level categories
<30
≥30

114 (85.1%)
20 (14.9%)

47 (75.8%)
15 (24.2%)

63 (94.0%)
4 (6.0%)
.005
Vitamin E level 9 (2.1–24.9) 9.8 (3.6–24.9) 8.4 (2.1–24.7)
Vitamin E–level categories
<5.5
≥5.5

15 (11.5%)
115 (88.5%)

4 (6.7%)
56 (93.3%)

11 (16.7%)
55 (83.3%)
.10
Reason for admission
LT
Other

43 (37.7%)
71 (62.3%)

21 (43.8%)
27 (56.2%)

48 (76.2%)
15 (23.8%)
<.001
Note. BMI = body mass index; LT = liver transplant; NASH = nonalcoholic steatohepatitis; SGA = subjective global assessment.
aThe numeric variables are given with the sample median (range) and the categorical variables are given with number (percent). The p values were calculated using either Fisher exact test or Wilcoxon rank sum test. The following variables have unavailable information: model for end-stage liver disease (n = 5), total cholesterol (n = 8), total lymphocyte (n = 5), transferrin (n = 9), albumin (n = 5), zinc level (n = 7), vitamin A level (n = 6), vitamin D level (n = 5), vitamin E level (n = 8), reason for admission (n = 23).

TABLE 3. - A Multivariable Analysis for Association of the Subjective Global Assessment at Initial Nutrition Status (Moderately or Severely Malnourished vs. Well Nourished) With Patients' Demographic and Clinical Characteristicsa
Variables OR (95% CI) p
Gender (male) 0.38 (0.16–0.95) .038b
Transferrin (≥200) 0.93 (0.40–2.19) .87
Albumin (≥3.4) 0.33 (0.14–0.80) .015b
Zinc level (≥0.66) 0.85 (0.28–2.59) .78
Vitamin D level (≥30) 0.85 (0.28–2.59) .059
Note. CI = confidence interval; OR = odds ratio; SGA = subjective global assessment.
aIn the multivariable logistic regression model, the probability was modeled for SGA at initial visit = moderately or severely malnourished as an event of success. The confounding factors that were significant at .05 levels in single variable comparison were included in the multivariable analysis. The variable “reason for admission” was not included in the multivariable analysis as some of the patients were admitted before they had their SGA at initial nutrition visit.
bIndicates significant p-value.

A multivariable linear regression was used to assess the association between hospital LOS (with a natural log-transformation) and SGA at initial nutrition visit while controlling for primary diagnosis (reason for LT evaluation) and laboratory measures such as transferrin, albumin, zinc, and vitamin D levels. The overall test p values obtained from the type III test were reported for this multivariable association analysis. No adjustment for multiple testing was done in these exploratory analyses. All two-sided p values of 0.05 or less were considered as statistically significant. Statistical analyses were performed using SAS (version 9.2; SAS Institute, Inc., Cary, NC) and R Statistical Software (version 2.11.0; R Foundation for Statistical Computing, Vienna, Austria).

Results

There were 134 patients who met our study's inclusion criteria. A summary of demographic and primary diagnosis information, as well as LOS if hospitalized, is provided in Table 4. A total of 129 patients were assigned an SGA score by a member of the nutrition team at each visit (five patients did not see the nutrition team) (see Figure 1). A total of 104 patients were hospitalized with a median LOS of 9 days (range: 1 –77 days). The most common reason for admission was for LT (n = 43), followed by hepatic encephalopathy (n = 18) and sepsis or infection (i.e., fever, spontaneous bacterial peritonitis) (n = 11). Forty-nine patients were readmitted; of these, 20 occurred within 30 days.

TABLE 4. - Study Cohort Information—Demographics, Overall Hospital LOS, and Primary Liver Disease Diagnosisa
Variables Overall Sample (N = 134)
Gender (male) 98 (73%)
Age at medical evaluation (years) 60 (29–73)
Race
White 104 (78%)
Other 30 (22%)
BMI 27.9 (19.4–44.2)
Hospital LOS (days) 9 (1–77)
Primary diagnosis
Viral (hepatitis B, C) 60 (44.8%)
Alcohol 26 (19.4%)
Cancer (HCC or cholangiocarcinoma) 1 (0.8%)
Biliary diseases (PBC, PSC, cholangiopathy) 9 (6.7%)
Blood disorder/thrombosis (Budd-Chiari, etc.) 0 (0.0%)
Autoimmune/inherited disorder/α 1 antitrypsin 7 (5.2%)
Acute liver failure/fulminant 1 (0.8%)
Cryptogenic/NASH 24 (17.9%)
Metabolic—Wilson's, hemochromatosis 1 (0.8%)
Other—polycystic, granulomatous, any other diagnosis 5 (3.7%)
Note. BMI = body mass index; HCC = hepatocellular carcinoma; LOS = length of stay; NASH = nonalcoholic steatohepatitis; PBC = primary biliary cirrhosis; PSC = primary sclerosing cholangitis.
aThe numeric variables are given with the sample median (range) and the categorical variables are given with number (percent).

FIGURE 1.
FIGURE 1.:
Nutritional status changes while awaiting liver transplantation (LT).

Table 5 outlines information regarding the SGA scores and degree of malnutrition noted at different clinic visits. At the time of the IE by a physician, 11% of patients were noted to have malnutrition, while 67 patients (52%) were documented to be moderately to severely malnourished at the initial nutrition assessment performed by the LD/RD. Table 5 presents clinical, laboratory, and vitamin levels, and reason for admission for the overall sample and according to SGA score at initial nutrition assessment (well nourished vs. moderately/severely malnourished). The median levels of transferrin, albumin, zinc, and vitamin were all statistically significantly lower in patients who were malnourished than in those who were well nourished. More of the moderately/severely malnourished patients (59.7%) were more likely to be admitted to hospital. There was no correlation between BMI and nutritional status.

TABLE 5. - Degrees of Malnutritiona
Variables Overall Sample (N = 134)
Malnutrition documented at the time of initial visit (by hepatologist) (yes) 15 (11.2%)
SGA at initial nutrition visit (n = 129; 5 patients did not see nutrition team)
Well nourished
Moderately (or suspected of being) malnourished
Severely malnourished


62 (48.1%)
48 (37.2%)
19 (14.7%)
SGA at second nutrition visit
Well nourished
Moderately (or suspected of being) malnourished
Severely malnourished

12 (15.2%)
53 (67.1%)
14 (17.7%)
SGA at third nutrition visit
Well-nourished
Moderately (or suspected of being) malnourished
Severely malnourished

3 (4.8%)
50 (79.4%)
10 (15.9%)
SGA at the time of LT
Well nourished
Moderately (or suspected of being) malnourished
Severely malnourished

28 (29.5%)
49 (51.6%)
18 (19.0%)
Note. LT = liver transplant; SGA = subjective global assessment.
aThe numeric variables are given with the sample median (range) and the categorical variables are given with number (percent). The following variables have unavailable information: SGA at initial nutrition (n = 5); SGA at second nutrition visit (n = 55); SGA at third nutrition visit (n = 71); and SGA at the time of orthotopic LT (n = 39).

In a multivariable logistic model that included patient's gender, transferrin, albumin, zinc, and vitamin D levels, only two covariates, gender (OR = 0.4, p = .038) and albumin levels (OR = 0.3, p = .015), were significantly associated with malnutrition (Table 5). This multivariable analysis indicated that the odds of being identified as moderately or severely malnourished were 0.4 times more likely for males than for females, and the odds of being identified as moderately or severely malnourished were 0.3 times more likely in patients with albumin level of 3.4 or more than in those with lower albumin levels (albumin level of <3.4).

Out of 134 patients, 101 received an LT (75%) during the time of this study. Of these 101 patients, 52% were noted to be either moderately or severely malnourished at the time of their initial nutrition visit, increasing to 67% at the time of LT. The changes in malnutrition status at second and third clinic visits and on admission for transplant were statistically significant when compared with SGA at initial nutrition visit (all p ≤ .007) (Tables 2 and 3). The hospital LOS was significantly associated with those patients identified as malnourished at the time of the initial physician evaluation (p = .046), SGA score at initial nutrition visit (p = .020), primary diagnosis (p = .001), transferrin (p = .002), albumin levels (p = .001), zinc levels (p = .008), and vitamin A levels (p < .001) in this single variable analysis.

In a multivariable regression analysis that included SGA at initial nutrition visit, primary diagnosis, transferrin, albumin, zinc levels, and vitamin A levels, the association of LOS with SGA at initial nutrition visit was statistically significant (p = .017), as was primary diagnosis (p = .007) and vitamin A levels (p = .014) SGA at second and third nutrition visits and SGA at the time of admission for LT were compared with the initial nutrition visit (SGA performed by LD/RD) (Table 6).

TABLE 6. - Subjective Global Assessment at Second and Third Nutrition Visits and at Admission for LT Compared With the Initial Nutrition Visit (SGA Performed by Licensed Dietitian/Registered Dietitian)a
Variables SGA at Initial Nutrition: Well-Nourished (n = 62) SGA at Initial Nutrition: Moderately or Severely Malnourished (n = 67) p
SGA at second nutrition visit
Well nourished
Moderately or severely malnourished

10 (42%)
14 (42%)

2 (4%)
53 (96%)
.004
SGA at third nutrition visit
Well nourished
Moderately or severely malnourished

1 (7%)
13 (93%)

2 (4%)
47 (96%)
.007
SGA at LT nutrition visit
Well nourished
Moderately or severely malnourished

25 (57%)
19 (43%)

2 (4%)
47 (96%)
<.001
Note. LT = liver transplant; SGA = subjective global assessment.
aThe following variables have unavailable information: SGA at initial nutrition visit (n = 5); SGA at second nutrition visit (n = 55); SGA at third nutrition visit (n = 71); and SGA at orthotopic LT nutrition visit (n = 39). The p values were obtained using McNemar's exact test for paired samples.

Discussion

Malnutrition in patients with cirrhosis is often underappreciated and untreated (Carvalho & Parise, 2006). There are several reasons for malnutrition in this patient population. Liver function declines in the presence of cirrhosis causing metabolic abnormalities, malabsorption, and a lack of ability to metabolize and save nutrients (Tsiaousi, Hatzitolios, Trygonis, & Savopoulos, 2008). Patients are frequently unable to consume sufficient oral intake because of early satiety, especially in those with ascites (Tsiaousi et al., 2008). As mentioned previously, vitamin and protein deficiencies are common (Montano-Loza, 2014; Venu et al., 2013). Maharshi et al. (2015) reported that malnourished patients had an increased number of hospitalizations, and mortality was increased. Another study noted that patients with cirrhosis consumed very low protein intake (76%), which was associated with malnutrition and mortality (Ney et al., 2015). Frequency of sepsis-related death is more common in the malnourished patient (Montano-Loza et al., 2012). Malnutrition has been associated with a poor quality of life and higher risk of variceal bleeding. Patients with cirrhosis with low muscle mass may be at a higher risk of hepatic encephalopathy (Montano-Loza, 2014).

Currently, there is no consensus on which nutrition assessment tool would be most effective in diagnosing the patient who has cirrhosis with malnutrition. The relationship between serum albumin levels and a 6-minute walking test with sarcopenia has been studied (Montano-Loza, 2014). In addition, a recent observational study noted that malnutrition has been associated with an impaired quality of life in patients with cirrhosis (Rojas-Loureiro, Servin-Caamano, Perez-Reyes, Servin-Abad, & Higuera-de la Tijera, 2017). Gimenes, Reis, da Silva, Silva, and Atila (2016) discussed a conceptual nursing model to assist bedside nurses with appropriate nursing diagnoses for those with advanced liver disease, focusing on nutrition and fluid balance. This approach could provide a framework for a practical nursing intervention that would improve patient safety measurement and outcomes (Gimenes et al., 2016).

Patients undergoing evaluation for LT are required to have a nutrition assessment according to the Centers for Medicare & Medicaid Services (Centers for Medicare & Medicaid Services, 2008; Martin et al., 2014). The nutrition evaluation is thorough and reviews underlying illness, physical examination, anthropometric measurements, and biochemical data, and is summarized using the SGA. The SGA is a useful tool to grade malnutrition in this patient cohort that has been well described in the literature (Lim, Kim, Park, & Kim, 2015; Plauth et al., 2006). Other tools have been utilized to assess malnutrition in select groups of patients including BMI, dry BMI, handgrip strength, and mid-arm circumference (Marr et al., 2017; Sharma et al., 2017). At the time of this study, the SGA tool was used in our practice in the assessment of patients undergoing evaluation for LT (Bauer et al., 2002; Vigano et al., 2014).

Only 15 patients (11%) of the study cohort were graded as malnourished by the physician seeing the patient at the time of the initial assessment, whereas the nutrition team (LD/RD) graded 48 (37%) patients with moderate malnutrition and 19 (15%) patients with severe malnutrition. Physicians correctly documented the majority of the more severe cases of malnutrition (15 of 19 patients; 79% of the time). Malnutrition worsened as patients waited for LT, particularly in those who progressed from mild to moderate malnutrition. This is consistent with prior studies (Maharshi et al., 2015; Martin et al., 2014). Maharshi et al. (2015) reported that approximately 60% of patients with liver disease had malnutrition. They noted that the prevalence of malnutrition increased with worsening severity of liver disease as assessed by the Childs-Pugh score (Maharshi et al., 2015). In our study, 71 (62.3%) of the patients were hospitalized while awaiting transplant, with readmissions occurring a total of 94 times in this patient group.

In our study cohort, only 20% of patients were started on supplemental feedings to improve their nutritional status. In a systematic review by Koretz (2014), 37 trials were compared investigating the utility of parenteral nutrition, enteral nutrition, or nutritional supplements in patients with liver disease. No nutritional supplement route was superior to any other (Koretz, 2014). The administration of enteral feeding was not the standard of care at our center for every severely malnourished patient. It was used more frequently in critically ill patients and in those who were severely cachectic with minimal physical reserve. Patients were encouraged to increase their oral intake in an effort to improve their nutritional status, rather than immediately instituting enteral therapy. We recognize that our study highlights an opportunity to develop a more consistent approach to address moderate to severe malnutrition in patients listed for LT, which has subsequently been incorporated into our current practice.

Although most clinicians believe that improving patients' nutritional status is associated with more favorable outcomes, there is little evidence in the literature that has documented improved patient outcomes with the reversal of sarcopenia (Koretz, 2014; Montano-Loza et al., 2012). The American Society for Parenteral and Enteral Nutrition recommends that patients have a nutritional assessment at the time of liver disease diagnosis and return at regular intervals for monitoring (Frazier, Wheeler, McClain, & Cave, 2012). The target daily intake is 25–40 calories/kg, including 0.8–1.5 g/kg/d of protein (Lalama & Saloum, 2016). Patients with liver disease are unable to maintain stored glycogen, and as a result, muscle is broken down to provide a source of energy. This process reduces the body's lean body mass. To reduce the risk of muscle loss, meals should be spaced out throughout the day, fasting should be avoided, and an evening protein snack should be given. Branch chain amino acids are recommended to assist the patient in achieving adequate amounts of daily protein (Lalama & Saloum, 2016).

The main limitation of our study was its retrospective nature. Nutrition assessments were performed by different LD/RDs in the absence of a specific protocol that addressed varying degrees of malnutrition. Patients were seen by multiple physicians and advanced practitioners in follow-up. We did not adjust for multiple testing because of the exploratory nature of the study, increasing the likelihood of obtaining a false-positive association.

Since the time of this study, several modifications to the screening, identification of, and prompt follow-up of patients with malnutrition have been implemented in our practice. Our nutrition team has placed a higher priority on return visits for those patients with cirrhosis and moderate to severe degrees of malnutrition. This study heightened the awareness of malnutrition in this patient population, and documentation of such is occurring more often.

Conclusions

Our study confirms that malnutrition is prevalent in the patient with cirrhosis and often milder degrees are underdiagnosed. However, the nutritional status of the patient changes while awaiting LT. In collaboration with nutrition specialists, nurses can provide valuable education and monitoring of patients with cirrhosis, which should facilitate interventions to optimize their nutritional status. Identification and early treatment of malnourished patients with cirrhosis may reduce morbidity and LOS prior to transplantation.

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