Malnutrition in the cirrhotic in-patient: An audit of prevalence, protein-energy requirement and the impact of clinical nutrition.
Dr Ciara Kelly, Dr Anna Tierney (Interns), Dr Grace Chan, Dr Cara Dunne, Dr Sara Naimimohasses (Specialist Registrars in Gastroenterology), Professor S. Norris, Professor S. McKiernan (Consultants in Gastroenterology/Hepatology)
Gastroenterology/Hepatology Department, St. James’s Hospital, Dublin 8, Ireland.
Cirrhosis is frequently complicated by protein-energy malnutrition (1), which is associated with high morbidity and mortality. Clinical nutrition input is essential in the management of these patients. The 2006 ESPEN (European Society for Clinical Nutrition and Metabolism) Guidelines on Enteral and Parenteral Nutrition in Cirrhosis recommend clinical nutritionists use simple bedside tools to identify patients at risk of under-nutrition (2). The guidelines recommend an energy intake of 35-40 kcal/kg body weight/day, and a protein intake of 1.2-1.5g/kg body weight/day. Supplemental enteral nutrition should be used where patients cannot meet their nutritional requirements orally. Parenteral nutrition is recommended in moderately or severely malnourished patients who cannot otherwise meet requirements (3).
Aims: To audit against the following standards: all patients with cirrhosis should be assessed for risk of under-nutrition. Recommended protein-energy intake and use of supplemental nutrition should reflect ESPEN guidelines.
All patients with cirrhosis admitted from 31/10/15 to 31/12/15 under the Gastroenterology/Hepatology teams were included. Data was obtained from patients’ charts and the electronic patient record.
18 patients were identified (15 male, 3 female, mean age 59). All were assessed for malnutrition. Mean follow up was 16 days. On admission, 72% and 94% of patients were not meeting their calorie and protein requirements respectively. 83% required supplemental enteral nutrition. On discharge, 56% and 44% of patients were not meeting calorie and protein requirements respectively.
Most subjects were not meeting nutritional requirements on admission when assessed by a clinical nutritionist, despite being assessed as having a low risk of malnutrition according to the Malnutrition Screening Tool (MST) performed by nursing staff. This highlights a potential limitation in the efficacy of the MST as a screening tool in this population. Use of supplemental nutrition in these patients reflects ESPEN guidelines. Protein-energy intake improved after nutritional consultation. However many patients were still not meeting nutritional requirements on discharge. In 2013, HIPE data recorded 987 in-patient admissions in Irish hospitals due to ‘cirrhosis and alcoholic hepatitis.’ Therefore the results of this ‘snapshot’ audit infer there is potentially a larger cohort of in-patients with cirrhosis whose nutritional requirements are not being optimised.