Determining Whether Low Protein Intake (<1.0 g/kg) Is a Risk Factor for Malnutrition in Patients with Cirrhosis

Abstract

Background: The prevalence of malnutrition in patients with cirrhosis is considerably high. Body mass index (BMI) is a well-known risk factor for malnutrition, but the other risk factors are unknown. We investigated the prevalence of malnutrition and its risk factors in patients with cirrhosis.

Methods: In total, 361 patients with cirrhosis were enrolled. Muscle quality and quantity were retrospectively assessed using the grip strength test and bioelectrical impedance analysis. Subjective global assessment (SGA) of malnutrition and dietary intake assessments were performed by a clinical dietician.

Results: The prevalence rates of sarcopenia, malnutrition assessed by SGA, and inadequate energy intake were 22.7%, 13.6%, and 27.5%, respectively. The prevalence of malnutrition evaluated using any of the assessment methods was 46.3%, and no significant difference was observed according to liver disease etiology. The prevalence of malnutrition increased with the increasing disease severity (p = 0.034) and decreasing BMI (p = 0.007). The prevalence of malnutrition was 64.4% in patients with protein intake <1.0 g/kg. Low protein intake, Child-Pugh C grade, older age, and low BMI were independent risk factors for malnutrition in multivariate analysis.

Conclusions: Low protein intake (<1.0 g/kg) is an independent risk factor for malnutrition in patients with cirrhosis.

Keywords: liver cirrhosis; malnutrition; protein.

Figure 1

Flowchart of the participant selection process.

Figure 2

Prevalence of malnutrition defined based on the assessment results of different evaluation methods. (A) The prevalence of malnutrition according to the etiology of cirrhosis. (B) The prevalence of malnutrition according to the SGA, sarcopenia status, and dietary intake by etiology of cirrhosis. (C) The prevalence of malnutrition according to disease severity. (D) The prevalence of malnutrition according to the SGA findings, sarcopenia status, and dietary intake by disease severity. (E) The prevalence of malnutrition according to one of the definitions of malnutrition based on the body mass index. (F) The prevalence of malnutrition according to the SGA results, sarcopenia status, and dietary intake by body mass index.

Figure 3

Degree of agreement between the definitions of malnutrition. Eighteen patients were diagnosed with malnutrition based on the sarcopenia status and SGA results, while 24 patients were diagnosed with malnutrition based on the sarcopenia status and dietary intake. Fourteen patients were diagnosed with malnutrition based on SGA results and dietary intake, and only eight patients fulfilled all the criteria for diagnosing malnutrition (sarcopenia, SGA, and dietary intake). The agreement (Cohen’s kappa value) among the sarcopenia, SGA, and energy intake-based methods was <0.217.

Figure 4

Receiver operating characteristic curve of factors affecting malnutrition. (A) Area under the curve of the factors affecting malnutrition based on the definition of malnutrition. (B) Area under the curve of factors affecting malnutrition based on sarcopenia. (C) Area under the curve of factors affecting malnutrition based on dietary intake. The estimated daily requirements were calculated using Schofield’s modification of the Harris–Benedict equation, and patients were screened for malnutrition if their total daily caloric consumption was lower than the estimated daily requirement. (D) Area under the curve of factors affecting malnutrition based on SGA.