Liver Disease Undernutrition Screening Tool Questionnaire Predicts Decompensation and Mortality in Cirrhotic Outpatients with Portal Hypertension.

BACKGROUND: Numerous scores are designed to predict outcomes of patients with liver cirrhosis. Our study aimed to evaluate the ability of the Liver Disease Undernutrition Screening Tool (LDUST) in predicting mortality and decompensation in outpatients with clinically significant portal hypertension (CSPH). We hypothesized that LDUST could help identify patients in need of nutritional supplementation and intervention. METHODS: A prospective study of 57 CSPH patients (36.8% female, mean age: 63.5 ± 9.9 years) with a median follow-up of 41 months was conducted. Baseline liver function, nutrition, and sarcopenia were assessed, alongside LDUST. During follow-up, the occurrence of liver decompensation, hospital admission, need for emergency care, and mortality were evaluated. RESULTS: A total of 56.1% of patients were Child A, and the most frequent etiology was alcohol (50.9%). Malnutrition risk according to LDUST raised mortality (HR: 25.96 (1.47-456.78)), decompensation (HR 9.78 (2.08-45.89)), and admission (HR 4.86 (1.09-21.61)) risks in multivariate Cox analysis. Combining LDUST with Child and MELD scores improved their decompensation prediction (0.936 vs. 0.811 and 0.866 vs. 0.700). CONCLUSIONS: The LDUST has a solid ability to predict complications in cirrhosis outpatients with CSPH, and its integration with Child and MELD models enhances their predictive power. LDUST implementation could identify individuals necessitating early nutritional support.

Randomized Clinical Trial: Effects of ß-Hydroxy-ß-Methylbutyrate (HMB)-Enriched vs. HMB-Free Oral Nutritional Supplementation in Malnourished Cirrhotic Patients.

ß-Hydroxy-ß-methylbutyrate (HMB) supplementation increases muscle and strength mass in some muscle-wasting disorders. Malnutrition and sarcopenia are often present in liver cirrhosis. We aimed to investigate the effects of oral HMB supplementation on changes in body composition and liver status in patients with cirrhosis and malnutrition. In a randomized, controlled, double-blind trial, 43 individuals were randomized to receive twice a day and for 12 weeks an oral nutritional supplement (ONS) enriched with 1.5 g of calcium HMB per bottle or another supplement with similar composition devoid of HMB. Inclusion criteria were liver cirrhosis with at least one previous decompensation and clinical malnutrition. Liver function, plasma biochemistry analyses, and physical condition assessment were carried out at baseline, then after six and 12 weeks of supplementation. A total of 34 patients completed the clinical trial. An improvement in liver function and an increase in fat mass index were observed in both groups. None of the two ONS changed the fat-free mass. However, we observed an upward trend in handgrip strength and a downward trend in minimal hepatic encephalopathy in the HMB group. At the end of the trial and regardless of the supplement administered, fat mass content increased with no change in fat-free mass, while liver function scores and nutritional analytic markers also improved.

Amino Acid Profile in Malnourished Patients with Liver Cirrhosis and Its Modification with Oral Nutritional Supplements: Implications on Minimal Hepatic Encephalopathy.

Low plasma levels of branched chain amino acids (BCAA) in liver cirrhosis are associated with hepatic encephalopathy (HE). We aimed to identify a metabolic signature of minimal hepatic encephalopathy (MHE) in malnourished cirrhotic patients and evaluate its modification with oral nutritional supplements (ONS) enriched with ß-Hydroxy-ß-methylbutyrate (HMB), a derivative of the BCAA leucine. Post hoc analysis was conducted on a double-blind placebo-controlled trial of 43 individuals with cirrhosis and malnutrition, who were randomized to receive, for 12 weeks, oral supplementation twice a day with either 220 mL of Ensure® Plus Advance (HMB group, n = 22) or with 220 mL of Ensure® Plus High Protein (HP group, n = 21). MHE evaluation was by psychometric hepatic encephalopathy score (PHES). Compared to the HP group, an HMB-specific treatment effect led to a larger increase in Val, Leu, Phe, Trp and BCAA fasting plasma levels. Both treatments increased Fischer's ratio and urea without an increase in Gln or ammonia fasting plasma levels. MHE was associated with a reduced total plasma amino acid concentration, a reduced BCAA and Fischer´s ratio, and an increased Gln/Glu ratio. HMB-enriched ONS increased Fischer´s ratio without varying Gln or ammonia plasma levels in liver cirrhosis and malnutrition, a protective amino acid profile that can help prevent MHE.

Mini Nutritional Assessment - Short Form Is a Useful Malnutrition Screening Tool in Patients with Liver Cirrhosis, Using the Global Leadership Initiative for Malnutrition Criteria as the Gold Standard.

BACKGROUND: The use of nutrition-screening tools in cirrhotic patients is not systematized. Recently, specific tools have been proposed for patients with cirrhosis, but their diagnostic capabilities have been scarcely studied. METHODS: This was a prospective study that includes outpatients with liver cirrhosis undergoing follow-up in the hepatology consultations of a tertiary-care university hospital. A trained gastroenterologist applied the screening tools: Liver Disease Universal Screening Tool (LDUST), Royal Free Hospital-Nutrition Prioritizing Tool (RFH-NPT), and Mini Nutritional Assessment-Short Form (MNA-SF). Subsequently, the diagnosis of malnutrition was made according to Global Leadership Initiative for Malnutrition (GLIM) criteria by an endocrinologist, who was blind to the results of the screening tools. RESULTS: Sixty-three patients (38.1% women, mean age 63.1 ± 9.9 years) with cirrhosis (60.3% Child-Pugh A, 34.9% Child-Pugh B, and 4.8% Child-Pugh C) were evaluated. The prevalence of malnutrition was 38.1% (15.9% moderate, 22.2% severe). Advanced stages of cirrhosis were associated with a higher prevalence of malnutrition (P = .021). MNA-SF was the most accurate screening tool, being superior to RFH-NPT and LDUST. It presented better sensitivity than RFH-NPT (88% [0.68-0.97] vs 67% [0.45-0.84], P = .031) and better specificity than both LDUST (97% [0.87-0.99] vs 62% [0.45-0.77], P < .001) and RFH-NPT (97% [0.87-0.99] vs 82% [0.67-0.93], P = .016). CONCLUSIONS: According to the GLIM criteria, malnutrition affected 38.1% of patients with cirrhosis, being severe in 22% of the patients. MNA-SF is the most accurate screening test, superior even to tools specifically designed for cirrhotic patients (LDUST).

Tratamiento actual de la hepatitis B: ¿dónde encajan los nuevos análogos de los núcleos(t)idos? / Current treatment of hepatitis B infection: where do the new nucleos(t)ide analogues fit in?

La aparición de los análogos de nucleós(t)idos ha sido uno de los avances más importantes en el tratamiento de la hepatitis crónica por infección del virus de la hepatitis B. Los primeros antivirales empleados presentaban una eficacia limitada por la tasa de resistencias elevada pero en los últimos años han aparecido nuevas moléculas (tenofovir, entecavir) con mayor potencia antiviral y menor tasa de resistencias, y por ello las guías clínicas más actuales los consideran de primera elección. No obstante, el interferón todavía puede tener un papel relevante en el tratamiento de la hepatitis B en pacientes seleccionados. Además, en determinadas circunstancias como la insuficiencia renal, el embarazo o la inmunodepresión no se ha definido con exactitud el papel de los nuevos antivirales orales.En esta revisión se analizan estos aspectos, así como algunas peculiaridades del manejo de los pacientes tratados con análogos de nucleós(t)idos (AU)

Introducción La aparición de los análogos de nucleósidos y nucleótidos ha sido uno de los avances más importantes en el tratamiento de la hepatitis crónica por infección del virus de la hepatitis B (VHB). El primer fármaco de administración oral que se aprobó fue la lamivudina en 1998, y posteriormente se han incluido otros 4 (adefovir, tenofovir, entecavir y telbivudina). También hay una combinación de emtricitabina y tenofovir (Trubada®), aprobada para el tratamiento de la infección por el virus de la inmunodeficiencia humana (VIH), y con eficacia demostrada frente al VHB. El VHB es un virus ADN que se replica casi exclusivamente en los hepatocitos, aunque se han detectado bajos niveles de replicación en otros tejidos como páncreas, riñón y linfocitos. Una vez que el virus entra en la célula hepática, la cápside se transporta hasta el núcleo donde se libera el ADN viral que formará el ADNccc (ADN circular covalentemente cerrado) a partir del cual se sintetizan los ARNm que, una vez pasan al citoplasma, dirigen la síntesis de las diferentes proteínas que darán lugar a las nuevas partículas virales. El HBcAg polimeriza alrededor del complejo de ribonucleoproteínas que contiene el genoma en forma de ARN para constituir las cápsides inmaduras. En éstas, a partir del ARN y mediante la polimerasa viral, que tiene acción transcriptasa inversa similar a la del VIH, se sintetizan las nuevas cadenas de ADN, con la consiguiente maduración de las partículas virales que pueden seguir 2 caminos: volver al núcleo para replecionar el ADNccc o bien (AU)

[Current treatment of hepatitis B infection: where do the new nucleos(t)ide analogues fit in?]. / Tratamiento actual de la hepatitis B: dónde encajan los nuevos análogos de los núcleos(t)idos?

One of the most important advances made in the treatment of chronic hepatitis B infection has been the development of nucleos(t)ide analogues. The first antiviral agents used had limited efficacy due to the high resistance rate. However, in the last few years, new agents (tenofovir, entecavir) have been developed with greater antiviral potency and a lower resistance rate. Consequently, these agents are considered to be the treatment of choice in the most recent clinical guidelines. Nevertheless, interferon may still play an important role in the treatment of hepatitis B in selected patients. Moreover, in some contexts, such as renal insufficiency, pregnancy or immunosuppression, the role of the new oral antiviral agents has not been precisely defined. The present review analyzes these aspects, as well as some of the particular features of the management of patients treated with nucleos(t)ide analogues.