Journal of Clinical and Diagnostic Research. 2019 May, Vol-13(5): OE01-OE05 1 1 DOI: 10.7860/JCDR/2019/38412.12822 Internal Medicine Section Malnutrition in Liver Cirrhosis: A Review Review Article INTRODUCTION Liver is the second largest organ in the human body. The liver is responsible for performing many functions in the body which include such as metabolisation, synthesis, detoxification and storage. Essential trace elements, such as iron and copper, and Vitamins A, D, and B12 are also stored in the liver. Liver is the most important metabolic organ that regulates physiological and biochemical processes including protein and energy metabolism. Malnutrition is a stipulation that results from an unbalanced diet in which certain nutrients are inadequate or in the altered ratio. There are several types of malnutrition including undernutrition and obesity (Overabundance of nutrient in diet). Because the major form of malnutrition in patient with cirrhosis is undernutrition or protein calorie malnutrition. The malnutrition in cirrhosis is characterised by decreased lean body mass as well as diminished skeletal muscle weight and reduced fat mass. In case of cirrhosis, malnutrition is the single reversible prognostic marker that accelerates deteriorating liver function [1,2]. METABOLIC FUNCTION OF THE LIVER Hepatocytes are metabolic overachievers of the liver and they play significant roles in the synthesis of molecules that are utilised at another place for the support of homeostasis, in converting molecules of one type to another, and also in regulating energy balances. CARBOHYDRATE METABOLISM Carbohydrate metabolism is a key biochemical process that ensures a constant supply of energy to living cells. The most important carbohydrate is glucose, which can be broken down via glycolysis, enter into the Kreb’s cycle and oxidative phosphorylation to generate ATP. It is essential for all animals to maintain the concentrations of glucose in blood within a normal range. Maintenance of normal blood glucose levels over both short (means hours) and long (means days to weeks) periods of time are one of the important functions of the liver. Glycogenesis results in the formation of complex glycogen from α D glucose in the cytoplasm of liver and muscle cells. DIAGNOSTIC CRITERIA OF LIVER CIRRHOSIS The natural course of fibrosis begins with a long-lasting instead asymptomatic period, called ‘compensated’ phase followed by a rapidly progressive phase, named ‘decompensated’ cirrhosis characterised by clinical signs of the liver function impairment (i.e., ascites, variceal bleeding, encephalopathy, jaundice). Liver cirrhosis represents the final stage of liver fibrosis, the wound healing response to chronic liver injury. Cirrhosis is characterised by distortion of the liver parenchyma associated with fibrous septae and nodule formation as well as alterations in blood flow. Details of the criteria for diagnosis of liver cirrhosis is summarised in [Table/Fig-1-3][3]. Common symptoms in cirrhosis include: •฀ Cutaneous฀signs฀of฀liver฀disease. •฀ A฀frm฀liver฀on฀palpation. •฀ Liver฀biopsy. SUMIT RUNGTA 1 , AMAR DEEP 2 , SUCHIT SWAROOP 3 Keywords: Carbohydrate metabolism, Lipid metabolism, Minerals, Protein calorie malnutrition, Protein metabolism, Vitamins ABSTRACT Malnutrition is a frequent and integral component of acute and chronic diseases and is most common in patients with cirrhosis and increase the severity of disease. Therefore, every hospitalised patient should have an assessment of their nutritional status. Patient with advanced liver disease commonly have malnutrition but its assessment is confounded by many of the usual indicators of nutritional status. The majority of cirrhotic patients unintentionally follow a low calorie diet, a fact that is attributed to various side- effects observed in cirrhosis. Protein Calorie Malnutrition (PCM) occurs in 50% to 90% of liver cirrhosis patients and progresses as liver function crumbled. This article is based on a selective literature review of protein and sodium recommendations. Higher intake of branched-chain amino acids and as well as vegetable proteins has shown benefits in liver cirrhotic patients. Sodium restrictions are necessary to prevent ascites development. Parameter 1 2 3 Ascites Absent Slight Moderate Encephalopathy None Grade 1-2 Grade 3-4 Bilirubin (mg/dL) <2 2-3 >3 Albumin (mg/dL) >3.5 2.8-3.5 <2.8 Prothrombin Time PT: 1-3 PT: 4-6 PT: >6 [Table/Fig-1]: Child-Pugh Score. Classification Stages METAVIR score F0-F3 F4 F4 F4 F4 HVPG (mmHg) >6 >10 >12 >16 and >20 Stage 1 Stage 2 Stage 3 Stage 4-5 Compensated Compensated and varices Decompensated, varices and ascites Decompensated variceal bleeding ascites other complications 1-year mortality (%) 1 3 10-30 60-100 [Table/Fig-2]: METAVIR Score (this table is modified from ref [3]). F: Fibrosis stage; HVPG: Hepatic venous pressure gradient