Impact of nutritional status on outcomes after liver transplantation.

BACKGROUND: Poor preoperative nutritional status has been reported to be associated with adverse outcomes after liver transplantation. Published data are, however, conflicting, with methods of preoperative nutritional assessment and postoperative outcomes varying between studies. METHODS: We prospectively studied the predictive value of preoperative nutritional status for adverse outcomes after liver transplantation. Assessment of preoperative nutritional status included: body cell mass determination, subjective global assessment, anthropometry, handgrip dynamometry, biochemical and amino acid profile, Child's score, and dual-energy x-ray absorptiometry. Death, intensive care unit (ICU) length of stay > or =4 days, hospital length of stay > or =15 days, blood usage > or =36 U of blood products, infection, rejection, and global resource utilization (an index of cost) greater than the median were considered poor outcomes. RESULTS: Fifty-three patients were studied. Longer ICU stay was associated with lower handgrip strength (P<0.01) and lower aromatic amino acid levels (P<0.01). Longer total hospital stay and the development of infections were associated with lower branched chain amino acid levels (P<0.01 and <0.001, respectively). Acute cellular rejection was associated with lower total body fat (P<0.001) and higher triglyceride levels (P<0.02). Neither death nor higher global resource utilization was associated with any preoperative nutritional parameter. CONCLUSIONS: Lower preoperative handgrip strength and branched chain amino acid levels are associated with longer ICU stays and increased likelihood of posttransplant infections. In our program, in which nutritional support was provided to potential recipients exhibiting malnourishment, none of the measured nutritional parameters were associated with mortality or greater global resource utilization.

Utility of standard nutritional parameters in detecting body cell mass depletion in patients with end-stage liver disease.

Protein-calorie malnutrition, best measured by body cell mass (BCM) depletion, has been associated with adverse outcomes in patients with end-stage liver disease. We prospectively measured BCM and multiple standard nutritional parameters in patients with end-stage liver disease to determine which, if any, of the traditionally measured nutritional parameters correlate with BCM. A detailed nutritional assessment, including BCM analysis, subjective global assessment, anthropometry, handgrip dynamometry, laboratory tests, and body composition measured by dual-energy X-ray absorptiometry was performed in 69 sequential patients awaiting liver transplantation. The frequency of abnormalities of specific parameters of nutritional status varied between 19% and 99%. Most of the commonly measured parameters of nutritional status correlated poorly with BCM. Patients with depleted BCM (lowest quartile for sex) had midarm circumference (P <.01), arm-muscle circumference (P <.001), handgrip strength (P <.001), blood urea nitrogen (P <.01), and creatinine (P <.01) values less than those for patients with greater BCM (highest 3 quartiles for sex). In multivariate analysis, arm-muscle circumference and handgrip strength were the best predictors of BCM. The combined criteria of handgrip strength less than 30 kg and arm-muscle circumference less than 23 cm have a sensitivity of 94% and a negative predictive value of 97% in identifying patients with depleted BCM. Although abnormalities of nutritional parameters are highly prevalent among patients with end-stage liver disease, most parameters of nutritional status do not correlate with BCM. In patients with end-stage liver disease, arm-muscle circumference and handgrip strength are the most sensitive markers of BCM depletion.