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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 13  |  Issue : 1  |  Page : 31-37

Nutrition status and its impact on quality of life and performance status in end-stage liver disease


Department of Food and Nutrition, Lady Irwin College, University of Delhi, New Delhi, India

Date of Web Publication29-Mar-2019

Correspondence Address:
Dr. Neha Bakshi
Lady Irwin College, University of Delhi, Sikandra Road, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_39_18

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  Abstract 


Aim: Malnutrition in end-stage liver disease (ESLD) patients has been associated with various prognostic factors. However, its effect on nonconventional parameters is least studied. The present exploratory study analyzes the impact of malnutrition on quality of life (QoL) and performance status (PS) in ESLD. Methods: We recruited 54 adult ESLD patients. Nutrition status assessment was performed by different validated tools such as subjective global assessment (SGA), mid-upper arm circumference, triceps skinfold measurements, mid-arm muscle circumference, and body mass index (BMI) for ascites. QoL and PS were assessed by Short Form-36 Interview and Eastern Cooperative Oncology Group-PS, respectively. Results: Malnutrition in patients ranged from 24.1% to 88.9% by various nutrition assessment techniques. ESLD patients showed lower levels of QoL and PS. SGA showed that malnourished patients had significantly lower PS grades than normal patients (P < 0.05). The Chi-square adjusted Z-scores showed that moderately malnourished patients had significantly higher PS-Grade-3 (capable of only limited self-care); further, severely malnourished patients had significantly higher PS-Grade-4 (completely disabled) (P < 0.004). Furthermore, malnutrition also showed lower QoL scores. After Bonferroni correction, SGA showed significantly lower emotional well-being scores of QoL in severely malnourished patients. BMI for ascites also showed significantly lower physical functioning and physical component summary scores of QoL among severely malnourished patients. Albumin level showed a significant positive correlation with emotional well-being of the patients.Conclusion: Hence, higher degree malnutrition among ESLD is associated with lower QoL and PS. The data addresses the need for planning nutrition interventions to ameliorate malnutrition in ESLD patients to improve QoL and PS for better prognosis.

Keywords: End-stage liver disease, nutrition status assessment, performance status, quality of life


How to cite this article:
Bakshi N, Singh K. Nutrition status and its impact on quality of life and performance status in end-stage liver disease. Indian J Transplant 2019;13:31-7

How to cite this URL:
Bakshi N, Singh K. Nutrition status and its impact on quality of life and performance status in end-stage liver disease. Indian J Transplant [serial online] 2019 [cited 2019 Apr 26];13:31-7. Available from: http://www.ijtonline.in/text.asp?2019/13/1/31/255176




  Introduction Top


According to the Institute of Health Metrics and Evaluation of Global Burden of Disease, deaths from cirrhosis in all age groups were ranked 15th in 1990 which increased to 13th by 2016. Hence, the higher rank by 2016 showed an increasing trend of death from cirrhosis in South Asia over a period of time.[1] Liver transplantation (LT) is the only treatment for end-stage liver disease (ESLD).[2] ESLD is the result of liver damage which has symptoms such as dark urine, jaundice, ascites, excessive fatigue, nausea, vomiting, weight loss, and malnutrition, which leads to the physical inability of patients to maintain normal performance status (PS) and quality of life (QoL).[3]

Malnutrition is present in patients with ESLD and is related to increased morbidity and mortality.[4],[5],[6],[7],[8] Patients with ESLD frequently have varied metabolic abnormalities of carbohydrate, lipid, and protein metabolism that lead to gradual deterioration of their present condition. Malnutrition has been associated with adverse outcomes, including reduced patient and graft survival after LT.[9] The accurate assessment of nutritional status in cirrhotics is difficult, largely because of overlap with other complications such as fluid retention and hypoproteinemia.[6],[9] The European Society of Parenteral and Enteral Nutrition (2006) recommended using simple bedside methods such as subjective global assessment (SGA)/anthropometry or body cell mass analysis for nutrition status assessment.[10],[11] Early nutrition intervention focusing on replenishment of the nutrient deficit can prolong life expectancy, improve QoL, diminish various ESLD complications, and prepare them for a more successful LT.[7],[12]

Many clinical research determines treatment efficacy by analyzing outcomes such as postoperative complications or laboratory results.[13] However, for expensive medical procedures (transplantation) that use limited health care resources (organ donations), it becomes necessary to analyze alternative end results such as QoL and PS to make appropriate and practical decisions in properly allocating limited resources.[14],[15] Especially in chronic diseases, where recovery from a disease is not always achievable, QoL and PS are important tools to gather information on the status of living of the patients and may help focus various interventions targeting improvement in the well-being of patients. QoL and PS are two parameters which have gained importance as an outcome for evaluating medical procedures.[16],[17],[18],[19],[20],[21],[22],[23],[24]

The relation of malnutrition with QoL and PS has not been studied much. It is essential to understand the relation of malnutrition with QoL and PS to analyze the complete well-being of the ESLD patients. It is a long-term disorder with only one treatment left and that is LT; not every patient has access to such an expensive treatment. Recent studies are focusing on nutrition interventions in ESLD or before LT to improve nutrition status not only to improve the outcome but also to reduce the future complications of the disease.[11],[12] This assessment will help to formulate holistic interventions for patient's well-being.


  Methods Top


Adult (age ≥18 years) patients suffering from ESLD from three multispecialty hospitals in Delhi and National Capital Region were approached. Fifty-eight patients were recruited after informed consent during the study period (September 2013 to June 2015). QoL, PS, and nutrition status information were collected. Ethical clearance was obtained from the Institutional Ethical Committee. Patients below 18 years of age and acute liver disease patients were excluded.

Data collection

Patient information regarding age, gender, nationality, employment status, and the diagnosis was collected. Clinical data such as etiology, presence and degree of ascites, serum albumin, total serum bilirubin, Child-Turcott-Pugh (CTP), and Model for ESLD (MELD) scores were gathered. The nutrition status assessment was performed by SGA, albumin levels, mid-upper arm circumference (MUAC), triceps skinfold thickness, mid-arm muscle circumference (MAMC), and body mass index (BMI) for ascites.[7] The QoL assessment was analyzed by Short Form (SF)-36 Questionnaire. PS assessment was done by the Eastern Cooperative Oncology Group (ECOG)-PS Grade.

Nutrition assessment

  • There are problems in identification of the best nutritional assessment method which could be considered as the gold standard that is low cost, accurate, and an easily applicable method. Hence, the study used different validated tools for nutrition status assessment of the patients[10],[11]
  • In the present study, various anthropometric parameters which were used to assess muscle and fat masses were MUAC, triceps skin-fold thickness, and MAMC to evaluate nutritional status in patients with ESLD. However, most of these easily applicable methods are confounded by significant fluid retention in cirrhotics (peripheral edema and ascites).[25] The present study used cutoffs proposed by Jellife et al., 1989 for analyzing the nutrition state of the patients by MAMC and triceps-skin fold;[26] measurements for MUAC were analyzed using UNICEF technical bulletin 13 cutoffs as there are no separate data for patients with liver disease.[27] BMI for ascites is considered better parameter to detect malnutrition in cirrhotic patients than BMI cutoff values. BMI for ascites considers nutrition state in patients with no ascites, moderate ascites, and tense ascites. Peripheral edema and removal of ascites do not affect the analysis to diagnose patients' nutrition state[7]
  • Many body protein concentrations (albumin, prealbumin, retinol-binding protein, and 24-h creatinine excretion) are affected by the symptoms of liver disease.[28] Serum albumin concentration and measurements of 24-h creatinine excretion are two biochemical markers of malnutrition related to ESLD patients.[29] Albumin is an important determinant of body's protein status and an important indicator of liver function; hence, we cannot ignore its effect on various prognostic factors, QoL and PS. Hence, albumin levels of 54 ESLD candidates were also considered for analysis of the nutrition state in the present study where albumin levels <3.5 g/l are considered malnourished
  • SGA approach is the preferred assessment method for ESLD patients.[30],[31],[32],[33] The five features of SGA formulated by Detsky et al., 1987 are (1) weight loss before 6 months; (2) dietary intake in relation to a patient's usual intake, duration, and percent of abnormal intake are also considered (starvation, hypocaloric liquids, full liquid diet, and suboptimal solid diet), (3) gastrointestinal (GI) symptoms such as anorexia, nausea, vomiting, and diarrhea (persisting for >2 weeks); (4) the patient's functional capacity from bedridden to full capacity; and (5) the metabolic demands of the body according to the present disease status.[34] SGA rank is given which indicates the patient's nutritional status. These categories are (1) well nourished, (2) moderate or suspected malnutrition, and (3) severe malnutrition.[34]


Short Form-36 Interview

SF-36 interview or questionnaire is a validated multicomponent health survey with 36 questions to assess QoL. It has eight scales as well as two summary scores of the physical and mental domain. The SF-36 is considered useful in comparing general and specific populations, estimating the burden of different diseases, different health benefits produced by different medical procedures or treatments, and individualized screening of patients. It includes 36 items divided into eight scales: physical functioning (PF), role limitation due to physical health (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitation due to emotional problem (RE), and mental health (MH). The two composite summary scores are mental component summary (MCS) and physical component summary (PCS). The scores range from 0 to 100, with higher scores depicting better QoL.[35]

Previous studies also depicted lower QoL in ESLD patients when compared to the normative population of the country.[36],[37],[38],[39] There is lack of Indian studies analyzing the QoL of ESLD patients. Hence, the present study aimed to calculate QoL scores of these patients. There are no normative data on QoL of Indians and ESLD patients; hence, the study used a control group (age- and sex-matched normal individuals) to analyze the difference in QoL scores.

Eastern Cooperative Oncology Group-performance status assessment

ECOG-PS is a standard tool for analyzing the impact of a disease on patient's daily living abilities. It shows the normal functioning of the patients; that is, the ability to take care of themselves, their daily activities, and physical abilities. The ECOG-PS has six grades from 0 to 5: 0 – fully active, able to carry on all pre-disease performance without restriction; 1 – restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work; 2 – ambulatory and capable of all self-care but unable to carry out any work activities, up and about >50% of waking hours; 3 – capable of only limited self-care, confined to bed or chair >50% of waking hours; 4 – completely disabled, cannot carry on any self-care, totally confined to bed or chair; 5 – dead. These scales have been extensively used to describe the progression of diseases and how the daily living ability of patients is affected by a variety of medical complications. Furthermore, PS is used as an indicator of treatment and predictor of long-term survival.[24]

Statistical analysis

Statistical analysis was carried out using the software package SPSS statistical package (Version 17.0; SPSS Inc., Chicago, IL, USA). The demographic and clinical variables of the recipients are expressed as (percent) frequencies and mean ± standard deviation. The Mann–Whitney U-test was used for QoL comparison between ESLD patients and control groups and also between BMI for ascites and QoL scales, as the standard deviation was high. The association of albumin levels with QoL was analyzed using Spearman's rank correlation. Kruskal–Wallis test with Bonferroni correction was used for comparison of malnutrition by SGA, anthropometry (MUAC, MAMC, and triceps), and biochemical parameter (albumin) with QoL scales. The Chi-square test was used to assess the categorical data of ECOG-PS and malnutrition by BMI for ascites, SGA, triceps, MAMC, and MUAC. The Chi-square test with adjusted Z-scores was used to analyze the degree of malnutrition with PS level. Fisher's exact test was used when sample size was small (expected frequencies <5). P < 0.05 was considered statistically significant.


  Results Top


Recipient characteristics

The demographic and prognostic characteristics of the patients are listed in [Table 1]. The mean age of the patients was 48.6 ± 9.9 years, 72.2% were males, and 61.1% were Indians. 75.9% of the patients were employed before the LT. The patient's diagnosis showed that 48.1% of the patients were suffering from viral liver disease and 22.2% of the patients were suffering from alcoholic liver disease. The clinical variables showed higher mean bilirubin levels (5.6 mg/dl) and lower albumin levels (2.2 g/l); 58.1% of the patients had tense ascites; mean CTP score was 10.01 ± 1.6; and MELD score was 18.68 ± 4.3.
Table 1: Demographic and prognostic characteristics

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Malnutrition in end-stage liver disease patients

The varied prevalence of malnutrition in [Figure 1] depicts SGA and albumin indicating 88.9% of the ESLD patients as malnourished and MAMC, indicating 51.9% as malnourished; BMI for ascites showed 35.2%, triceps skinfold thickness depicted 27.9%, and MUAC showed 24.1% as malnourished.
Figure 1: Malnutrition in ESLD by various assessment tools. SGA: Subjective global assessment, MUAC: Mid-upper arm circumference, Triceps, MAMC: Mid-arm muscle circumference, BMI: Body mass index for ascites, ESLD: End-stage liver disease

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Quality of life and malnutrition

The analysis depicted in [Table 2] showed low mean scores in all the eight SF-36 scales of QoL in ESLD patients. The patients scored less than the mean score (50 ± 10) in the eight scales implying low QoL according to Medical Outcome Study-1992.[35] The normative data for ESLD patients and Indians were not available; hence, the eight scales of QoL were compared to the age- and sex-matched control from the general population which showed significantly lower PF, VT, MH, SF, BP and GH, PCS and MCS in LT recipients with a P < 0.05. This showed the level of impairment of QoL by the liver disease [Table 2].
Table 2: Quality of life of end-stage liver disease patients and control

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The nutrition status by different nutrition assessment tools of the patients was compared with QoL Scales [Table 3]. SGA showed significantly lower emotional well-being scores in severely malnourished than moderately malnourished (P = 0.042) and normal patients (P = 0.027). BMI for ascites showed significantly lower PF and PCS scores of QoL among malnourished patients [Table 3]. Furthermore, levels of albumin showed a significant and a positive correlation (r = 0.326, P = 0.016) with emotional well-being/MH of the ESLD patients [Table 3]. Lower QoL scores were also seen in malnourished ESLD patients by other nutrition assessment tools (MUAC, triceps, and MAMC), but the results were not significant [Table 3].
Table 3: Quality of life scales and malnutrition

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Eastern Cooperative Oncology Group-performance status and malnutrition

The PS assessment in ESLD patients showed [Figure 2] 46.3% of the patients in PS-Grade-2 (ambulatory and capable of all self-care but unable to carry out any work activities, up and about >50% of waking hours), 31.5% in PS-Grade-3, 14.8% in PS-Grade-4, and no deaths were recorded (PS-Grade-5).
Figure 2: ECOG performance status of pre-LT patients. ECOG: Eastern Cooperative Group Oncology Group, LT: Liver transplantation

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ECOG-PS Grades of patients undergoing LT were analyzed with nutrition status. SGA was the only nutrition assessment tool which showed that malnourished patients had significantly lower PS grades (P < 0.05). In other words, malnourished patients were functionally unable to maintain a good PS. Moderately malnourished patients were mainly in lower grades of ECOG-PS-2, -3, and -4, which showed the inability of the patients' to maintain normal PS to carry out daily routine activities [Table 4].
Table 4: Malnutrition and Eastern Cooperative Oncology Group-performance status

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The post hoc analysis of Chi-square adjusted Z-scores in [Table 4] showed that moderately malnourished patients had significantly higher PS-Grade-3 (capable of only limited self-care). In addition, severely malnourished ESLD patients had significantly higher PS-Grade-4 (completely disabled) (P < 0.004).

The data clearly depict lower performance status of the patients with higher degree of malnutrition.


  Discussion Top


QoL and PS are new outcome measuring techniques for chronic disease treatments.[17],[18],[19],[20],[21],[22],[23],[40],[41],[42] Nutrition has been considered as an important prognostic and therapeutic variable in liver disease and LT.[43],[44],[45] Malnutrition in ESLD patients has varied etiology from decreased intake (anorexia, ascites, encephalopathy, altered gustatory sensation), decreased absorption (inadequate bile flow, pancreatic insufficiency), metabolic alterations (increased resting energy expenditure and protein requirements, postprandial gluconeogenesis, fat malabsorption) to various iatrogenic factors (overzealous dietary restrictions, frequent paracentesis).[46] Malnutrition has been associated to various poor outcomes such as a lower patient and graft survival, longer intensive care unit days, ventilator, hospital days, higher blood product usage, damage of hepatocytes, the prognosis of diseases, posttransplant infections, a higher degree of ascites and encephalopathy in ESLD patients.[8],[30],[43],[44],[47],[48],[49],[50],[51],[52],[53]

The varied prevalence of malnutrition by different nutrition assessment tools in [Figure 1] depicts highest prevalence of malnutrition by SGA and albumin and lowest by MUAC. Hence, a correct nutritional evaluation of ESLD patients requires a combination of various tools such as SGA, anthropometry (MAMC, MUAC, and triceps) and biochemical parameters (albumin) to provide the correct picture of nutrition status.[54]

Nutritional status of the hemodialysis, institutionalized elderly, and cancer patients has been analyzed with QoL.[55],[56],[57] QoL assessment in liver disease patients is mostly determined by the severity of disease, pain, depression, decreased appetite, fatigue, and disease stage and transplant history. Interventions focusing on these symptoms improve the overall well-being of patients.[58] Decompensated cirrhosis patients have lower QoL;[39],[59] CTP scores were also closely associated with QoL.[60] Malnourished liver cirrhotics also showed that lower QoL scales and improved QoL have been depicted with nutrition supplementation.[61]

The present study depicted that ESLD patients had lower QoL. There are very few studies focusing on the relation of QoL and malnutrition in ESLD patients. Previous studies have shown individual associations of QoL and malnutrition in ESLD or on liver transplant recipients.[5],[6],[7],[8],[17],[18],[19] The present data showed lower QoL in six out of eight scales and the two composite scores in ESLD patients [Table 2]. Lower QoL scores were also seen in malnourished patients as assessed by various nutrition assessment tools. Significantly lower scores for QoL scales such as PF and PCS were seen in malnourished patients by BMI for ascites. Albumin levels showed significant and positive correlation with MH (P < 0.05), that is, higher albumin levels were related to better emotional well-being/MH in ESLD patients [Table 3]. According to SGA, severely malnourished patients had significantly lower emotional well-being scores than the moderately malnourished and normal patients [Table 3]. Hence, the data showed that a higher degree of malnutrition in ESLD is associated with lower emotional well-being/MH.

PS assessment of the patients is to analyze the actual level of ability of self-care. Several major surgeries have repeatedly demonstrated that PS is an important prognostic factor for survival.[4],[5],[6] Studies found that hepatocellular carcinoma (HCC) patients with poor PS were associated to higher CTP and MELD scores,[62],[63] larger or more HCC nodules, frequent vascular invasion, older age, alcoholism, diabetes mellitus, and reduced longevity.[21],[22],[23],[24] There are very few studies focusing on PS of ESLD patients. Studies that have used to ECOG-PS scale to assess the functional ability of the patients showed a low level of PS Grade in ESLD patients. A study by Plank et al. 2001 used ECOG-PS as a determinant for the impact of immune nutrition in LT patients. The ESLD patients had PS-Grade 0 (fully active) after immune supplementation.[40] Studies showed that lower PS has an association with higher mortality after LT.[41],[42]

The present study showed lower PS in ESLD patients [Figure 2]; 46.3% of the patients were in ECOG-PS Grade-2 (ambulatory and capable of all self-care but unable to carry out any work activities), 31.5% in ECOG-PS Grade-3 and 14.8% in Grade-4. Various studies have individually focused on the urgency of interventions focusing on improving malnutrition and PS of the ESLD patients.[20],[21],[22],[23],[62],[63],[64] However, there is a dearth of information on the association of malnutrition and PS in ESLD patients. Hence, the present study provides the much-needed information on the relation of malnutrition and PS of ESLD patients. [Table 4] shows significantly lower PS grades in malnourished pre-LT patients (moderate and severe) than the normal patients (P < 0.05) using SGA as a nutrition assessment tool. In addition, the moderately malnourished patients had significantly higher PS-Grade-3 (capable of only limited self-care) and severely malnourished patients had significantly higher PS-Grade-4 (completely disabled) (P < 0.004), depicting the impact of higher degree of malnutrition on lower PS [Table 4].

The present study showed that ESLD patients suffered from malnutrition and lower QoL and PS and also provided the much-needed information of association of higher degree of malnutrition in ESLD associated with lower QoL and PS.


  Conclusion Top


Considering the level of malnutrition, poor functional status, and lower QoL scores in ESLD patients, it is important to analyze these parameters together. The above data analyzed that malnutrition in ESLD patients is significantly related to poor QoL and PS. Hence, interventions focusing on improving the nutritional state can help to improve the nonconventional parameters (QoL and PS), which can lead to holistic well-being of the patient.

Acknowledgment

We would like to acknowledge Dr. A.S. Soin, Chief Hepatobiliary and Liver Transplant Surgeon and Chairman of Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, India; Dr. Subash Gupta, Chief Liver Transplant/HPB Surgeon and Director, CLBS, Indraprastha Apollo Hospital, New Delhi, India; and Dr. Vivek Vij, Director, Liver Transplant and GI surgery Fortis Hospital, Noida, for permitting the author to collect information regarding liver transplant patients from their institutes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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