This study of nutritional assessment in Malaysian patients with advanced cirrhosis has several limitations. The sample size was small, resulting in some limitations with the relevance of the results from the study. Furthermore, the study was conducted on a selected group of patients with cirrhosis, namely those with advanced end-stage disease who had been admitted to hospital for decompensation. Additionally, a significant proportion of patients with ascites did not have dry weight measurements done, which could have influenced BMI and calorie calculation results. Nevertheless, this study provides useful nutritional data which is currently lacking among Asian patients with advanced cirrhosis.
This study demonstrated that the prevalence of malnutrition, defined by MAMC < 5th
percentile, was 50% in Malaysian patients with advanced cirrhosis. The patients with cirrhosis exhibited a range of nutritional abnormalities, with protein-energy malnutrition of 50% (MAMC < 5th
percentile) and fat store depletions of 30% (TST <5th
percentile). BMI measurements in less malnourished cirrhotic patients were not different from the general population, mainly due to the fact that ascites and peripheral oedema contributed significantly to body weight in cirrhotic patients, and true lean body mass was not taken into account [21
]. The poor caloric intake of 15.2 kcal/kg/day is lower than the recommended level (24 - 40 kcal/kg/day [22
]), and may have been one of the causes of this malnutrition, although other factors are well recognized [3
The level of malnutrition identified in this study appears to be comparable to published data from Italy (34% of cirrhotics with MAMC < 5th
], a hospital-based study of 315 patients from France (58.7% of Child-Pugh C cirrhotic patients with MAMC < 5th
] and a previous study from Thailand (38% of cirrhotics with TSF <10th
]. This data suggests that nutritional deficiencies in cirrhosis are likely to be uniform worldwide, regardless of the ethnic distribution or socioeconomic status (believed to be higher in Western patients compared to Asians) of the population involved.
This study further supported the utility of the SGA in Asian patients with cirrhosis. Although anthropometric tools such as the MAMC and hand grip strength are known to be better predictors of malnutrition in adult patients with cirrhosis [15
], these tools are not necessarily practical for everyday use. The SGA, compared to standard anthropometry, is much more applicable in clinical practice and has previously been demonstrated to be highly predictive of malnutrition in advanced cirrhosis [24
]. We demonstrated in this study that SGA grade C patients with cirrhosis had significantly lower anthropometric measurements compared to SGA grade B cases, indicating that the SGA was able to differentiate nutritional status fairly well.
In terms of clinical severity, we were able to demonstrate a trend towards a higher proportion of SGA grade C in patients with Child-Pugh C cirrhosis compared to Child-Pugh B disease. The lack of statistical significance in this observation was probably a result of the small sample size of our study population, i.e. a Type II statistical error. Furthermore, the caloric intake in patients with more advanced cirrhosis was significantly lower with a likelihood of more malnutrition in this group. In this study, we demonstrated that serum visceral protein levels did not differ significantly between SGA Grade B and C, but varied markedly between Child-Pugh B and C liver disease. This indicated that visceral proteins were not influenced by nutritional status but more by the severity of hepatic dysfunction [25
Differences in malnutrition between various aetiologies of cirrhosis were explored in this study. The frequency of malnutrition in alcohol-related cirrhosis was higher than other aetiologies and the SGA demonstrated a trend towards more severe malnutrition in adults with alcoholic cirrhosis compared to other types of cirrhosis. The latter was not statistically significant, probably as result of the small number of patients in this study. One of the possible explanations for this finding was that 7/12 alcoholic patients were still actively consuming alcohol at the time of the study, leading to more severe nutritional deficiencies in these patients as previously reported [10
]. Our findings are in agreement with studies that have been conducted in larger populations. In a study of 1402 patients with cirrhosis in Italy, there was a higher incidence of malnutrition in alcoholic cirrhosis patients compared to other aetiologies of liver cirrhosis [26
]. In a Thai study of 60 patients with cirrhosis, the degree of malnutrition was higher in patients with alcoholic cirrhosis and these patients had more complications of cirrhosis compared to other aetiologies [24