Cruz Christofer, Prado Carla M, Gillis Chelsia, Martindale Robert, Bémeur Chantal, Lai Jennifer C, Tandon Puneeta
Department of Medicine, Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada.
Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada.
Hepatology. 2024 Mar 28. doi: 10.1097/HEP.0000000000000818.
Malnutrition, sarcopenia (low muscle mass), and physical frailty have gained increasing recognition in candidates for liver transplant (LT) as these conditions can impact postoperative functional capacity. Multidimensional prehabilitation programs have been proposed as a safe intervention in adults awaiting LT but the nutritional pillar of prehabilitation has been understudied. This review summarizes the nutritional recommendations for prehabilitation for individuals with cirrhosis awaiting LT. Three major aspects of nutritional prehabilitation are discussed: (1) Assess: Evaluate nutritional status and assess for malnutrition, sarcopenia, and frailty to guide the nutritional prehabilitation intervention intensity, increasing across universal, targeted, and specialist levels; (2) Intervene: Prescribe a nutritional prehabilitation intervention to meet established nutrition guidelines in cirrhosis with a targeted focus on improving nutritional status and muscle health; (3) Reassess: Follow-up based on the required intensity of nutritional care with as needed intervention adjustment. Topics covered in the review include nutritional care levels for prehabilitation, energy prescriptions across body mass index strata, detailed considerations around protein intake (amount, distribution, and quality), carbohydrate and fat intake, other nutritional considerations, and the potential role of dietary supplements and nutraceuticals. Future research is warranted to more accurately evaluate energy needs, evaluate emerging dietary supplementation strategies, and establish the role of nutraceuticals alongside food-based interventions. While the general principles of nutritional prehabilitation are ready for immediate application, future large-scale randomized controlled trials in this space will help to quantify the benefit that can be gained by transitioning the LT approach from passive "transplant waitlist time" to active "transplant preparation time."
营养不良、肌肉减少症（肌肉量低）和身体虚弱在肝移植（LT）候选者中越来越受到关注，因为这些情况会影响术后功能能力。多维度术前康复计划已被提议作为等待LT的成年人的一种安全干预措施，但术前康复的营养支柱尚未得到充分研究。本综述总结了等待LT的肝硬化患者术前康复的营养建议。讨论了营养术前康复的三个主要方面：（1）评估：评估营养状况，评估是否存在营养不良、肌肉减少症和虚弱，以指导营养术前康复干预强度，从普遍、有针对性到专科水平逐步增加；（2）干预：开出营养术前康复干预处方，以符合肝硬化既定的营养指南，有针对性地关注改善营养状况和肌肉健康；（3）重新评估：根据所需的营养护理强度进行随访，并根据需要调整干预措施。综述涵盖的主题包括术前康复的营养护理水平、不同体重指数分层的能量处方、蛋白质摄入（量、分布和质量）的详细考虑、碳水化合物和脂肪摄入、其他营养考虑以及膳食补充剂和营养保健品的潜在作用。有必要进行未来研究，以更准确地评估能量需求、评估新出现的膳食补充策略，并确定营养保健品与基于食物的干预措施相比的作用。虽然营养术前康复的一般原则已可立即应用，但该领域未来的大规模随机对照试验将有助于量化将LT方法从被动的“移植等待名单时间”转变为主动的“移植准备时间”所能获得的益处。
