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Objectives: Simple clinical tools are needed to detect malnutrition in cirrhotic patients. We have validated optimal body mass index (BMI) cut-offs for the diagnosis of malnutrition in accordance with the importance of ascites., Methods: BMI, mid-arm muscle circumference (MAMC) and triceps skinfold thickness (TST) were measured before paracentesis in study (SP) and validation (VP) populations of 875 and 294 cirrhotic patients, respectively with no ascite (NA), mild (MA), tense ascites (TA) (NA/MA/TA: SP: 327, 270, 278; VP: 111, 69, 114). Preserved nutritional status (SP: 259; VP: 93), malnutrition including severe and moderate malnutrition (SP: 251 and 365; VP: 92 and 109) were defined from MAMC and TST measurements., Results: Optimal BMI cut-off values were 22, 23 and 25 kg/m2 in NA, MA and TA patients, respectively. In the whole SP and VP, sensitivities of these cut-offs were 86.2% and 89.1%, respectively; the corresponding negative predictive values (NPV) for the diagnosis of severe malnutrition were 92.3% and 93.2%; specificities and positive predictive values (PPV) were 87.7% and 89.9%, 92.7% and 93.6%, respectively for the diagnosis of malnutrition. In the entire VP, peripheral oedema did not change sensitivity and NPV of BMI cut-offs for the diagnosis of severe malnutrition and tended to increase specificity and PPV for the diagnosis of malnutrition. 96.7% of the malnourished TA patients in the VP before paracentesis were correctly identified after removal of ascites., Conclusion: BMI is a reliable parameter to detect malnutrition in cirrhotic patients with the above mentioned cut-offs. Peripheral oedema and removal of ascites do not affect its diagnostic performance.

Objectives: To determine among severely malnourished cirrhotic patients remaining anorectic during hospital stay which patients may benefit from enteral nutrition in clinical practice., Methods: A prospective study including malnourished cirrhotic patients fed by enteral nutrition because of inadequate dietary intake after one-month hospitalization was carried out in a department receiving patients from other hospitals. Patients who died during hospital stay (N=35, group I) were compared to surviving patients (N=28, group II)., Results: Nutritional status and spontaneous dietary intake on admission to our department were in the same range in the two groups, Pugh score was higher in group I (11.1 +/- 1.9 vs 9.1 +/- 2.0, P=0.0001). The delay between previous hospital admission and the outset of enteral nutrition was comparable in the two groups. Its duration and total dietary intake during enteral nutrition were higher in group II (respectively 42.2 +/- 30.9 vs 15.2 +/- 33.1 days, P=0.0016 and 41.1 +/- 13.0 vs 29.9 +/- 10.0 kcal/kg/d, P=0.0004). Prevalence of side effects was higher in group I (54.3 vs 17.9%, P=0.0031). Multivariate analysis showed that Pugh score and septic complications were negatively associated with survival (respectively P=0.0196 and P=0.0078) while duration of enteral nutrition was positively associated (P=0.0435). Eighty six per cent of patients receiving enteral nutrition with bilirubin levels above 74 micromol/L on admission to our department died during hospital stay. Mid-term effects of enteral nutrition in surviving patients were improvement in Pugh score (7.5 +/- 2.0 vs 9.1 +/- 2.0, P<0.0001) and increase in spontaneous caloric and protein intake (29.7 +/- 15.3 vs 18.1 +/- 10.1 kcal/kg/d, P=0.0150 and 1.0 +/- 0.5 vs 0.6 +/- 0.3 g/kg/d, P=0.0049)., Conclusions: In severely malnourished cirrhotic patients remaining anorectic after one-month hospitalization, patients with bilirubin level below 74 micromol/L may benefit from six-week enteral nutrition with mid-term improvement in liver function and increase in spontaneous dietary intake.

Objective: We evaluated the impact of malnutrition and nutrition practice in 396 hospitalized cirrhotic patients (Child stages A, B, and C: 60, 169, and 167 patients) in a readaptative unit for liver diseases., Methods: Triceps skinfold thickness and mid-arm muscle circumference were measured at admission, and spontaneous dietary intake was evaluated at admission and during hospital stay., Results: Ascites was associated with impairment of nutrition status: 49% and 30.4% of non-ascitic patients, 49.1% and 40.5% of patients with mild ascites, and 65.5% and 48.3% of patients with tense ascites had mid-arm muscle circumferences and triceps skinfold thicknesses, respectively, below the fifth percentile of a reference population (P < 0.05 and P = 0.02, respectively). Decrease in dietary intake paralleled worsening of liver failure: 48% and 34% of Child A patients, 51.7% and 35.8% of Child B patients, and 80.3% and 62.9% of Child C patients at admission had caloric intakes below 30 kcal/kg of body weight and protein intakes below 1 g/kg of body weight, respectively (P < 0.001). Mortality rate was 15.4% during hospital stay; Child-Pugh score (P = 0.0014), age (P = 0.0029), severe septic complications (P = 0.0050), and decrease in caloric intake during hospital stay (P = 0.0072) were independently associated with mortality. Twenty-four patients received enteral feeding that was initiated before admission in four patients and after 12.4 +/- 8.3 d of hospitalization in 20 patients because of low caloric intake (<25 kcal/kg) despite oral supplements. Patients receiving enteral feeding were older (P < 0.01), had a higher Child-Pugh score (P < 0.01), and a higher mortality rate (P < 0.001) than other patients., Conclusions: Hospitalized cirrhotic patients have a high prevalence rate of malnutrition, and most do not satisfy their nutritional requirements. Decrease in caloric intake is an independent risk factor of short-term mortality. Enteral nutrition after failure of oral supplementation has no clinical benefit. Tube feeding may be indicated earlier in the course of the disease.