Underestimating the prevalence of malnutrition and sarcopenia
The prevalence of sarcopenia in patients who have cirrhosis ranges from 30% to 70%, depending on the diagnostic tools used and the severity of the underlying liver disease,9 but a malnutrition diagnosis might be missed because the condition can be undetectable in the early stages of liver disease. Furthermore, many factors can hide nutritional alterations in chronic liver disease, for example, some patients may appear overweight or obese despite being, at the same time, muscle depleted.10,11
For these reasons, it is helpful to apply a rapid screening approach that is able to identify those patients at risk of malnutrition. As shown in figure 1, patients at risk are those with a low BMI (<18), advanced liver disease (as revealed by a Child–Pugh class C score) or a positive score assessed by the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT). The latter score is based on six questions that assess nutrient intake, weight loss, subcutaneous fat loss, muscle mass loss, fluid accumulation and a decline in the functional status of the liver.3,12,13 Following this rapid screening approach, a complete nutritional assessment should be performed in all patients at risk (figure 1). This assessment should involve the muscle mass and muscle strength assessments described in Mistake 1, as well as global physical performance assessments, such as the timed up and go test (TUG), which measures the likelihood of falls and the six minute walk test (6MWT), which assesses aerobic capacity and endurance.14,15
Figure 1 | Rapid nutritional screening can be used to identify patients with chronic liver disease who are ‘at risk’ of malnutrition and should undergo a nutritional assessment. 6MWT, 6 minute walk test; BIA, bioelectrical impedance analysis; BMI, body mass index; CT, computed tomography; DEXA, dual-energy X-ray absorptiometry; RFH-NPT, Royal Free Hospital-Nutritional Prioritzing Tool; TUG, timed up and go test.
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