Mishra Saurabh, Premkumar Madhumita
Department of Gastroenterology and Hepatology, Paras Health, Sector-22, Panchkula, Haryana, 134109, India.
Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India.
J Clin Exp Hepatol. 2023 Sep-Oct;13(5):878-894. doi: 10.1016/j.jceh.2023.03.012. Epub 2023 Apr 6.
Nearly two-thirds of patients with cirrhosis suffer from malnutrition resulting from multiple contributory factors such as poor intake, accelerated starvation, catabolic milieu, and anabolic resistance. Nutritional assessment and optimization are integral to adequate management of a liver transplant (LT) candidate. A detailed nutritional assessment should be done at baseline in all potential transplant candidates with periodic reassessments. Sarcopenia is defined as a reduction in muscle mass, function, and/or performance. Skeletal muscle index at 3rd lumbar vertebra determined by computed tomography is the most objective tool to assess muscle mass. Hand-grip strength and gait speed are simple tools to gauge muscle strength and performance, respectively. Sarcopenia, sarcopenic obesity, and myosteatosis portend poor outcomes. Sarcopenia contributes greatly to frailty, which is a syndrome of reduced physiological reserve and impaired response to stressors. Dietary interventions must ensure adequate calorie (35-40 kcal/kg/day) and protein (1.2-1.5 gm/kg/day) intake via multiple frequent meals and late-evening calorie-dense snack. Micronutrient supplementation is essential, keeping in mind the etiology of cirrhosis. Individualized, gradually up-titrated exercise prescription consisting of both aerobic and resistance training of 150 min/week is advisable after appropriate risk assessment. Early initiation of enteral nutrition within 12-24 h of LT is recommended. Data with respect to immune-nutrition, monomeric formulas, and hormone replacement remain conflicting at present. A multidisciplinary team comprising of hepatologists, transplant surgeons, intensivists, dieticians, and physiotherapists is vital to improve overall nutrition and outcomes in this vulnerable group.
近三分之二的肝硬化患者存在营养不良，这是由多种因素共同导致的，如摄入不足、饥饿加速、分解代谢环境和合成代谢抵抗。营养评估和优化对于肝移植（LT）候选者的充分管理至关重要。应对所有潜在的移植候选者在基线时进行详细的营养评估，并定期重新评估。肌肉减少症的定义为肌肉质量、功能和/或表现的下降。通过计算机断层扫描测定的第三腰椎水平的骨骼肌指数是评估肌肉质量最客观的工具。握力和步速分别是衡量肌肉力量和表现的简单工具。肌肉减少症、肌肉减少性肥胖和肌脂肪变性预示着不良预后。肌肉减少症极大地导致了虚弱，虚弱是一种生理储备减少和对应激源反应受损的综合征。饮食干预必须通过多次少食多餐和晚间高热量零食确保足够的热量（35 - 40千卡/千克/天）和蛋白质（1.2 - 1.5克/千克/天）摄入。考虑到肝硬化的病因，补充微量营养素至关重要。在进行适当的风险评估后，建议制定个性化的、逐渐增加剂量的运动处方，包括每周150分钟的有氧运动和抗阻训练。建议在肝移植后12 - 24小时内尽早开始肠内营养。目前关于免疫营养、单体配方和激素替代的数据仍存在冲突。由肝病学家、移植外科医生、重症监护医生、营养师和物理治疗师组成的多学科团队对于改善这一弱势群体的整体营养状况和预后至关重要。
