TO THE EDITOR
We read the article published by Carteri et al[1] in the World Journal of Hepatology journal with great interest. This particular study is significant, particularly with its 15-year longitudinal follow-up, reaffirming the prognostic value of the Child-Turcotte-Pugh (CTP) score in patients with cirrhosis. However, the interpretation of the findings regarding nutritional assessment warrants further discussion. Although the authors concluded that nutritional indicators were not shown a statistically significantly associated with survival, several other factors should be considered. Herein, we highlight the nutritional predictors of survival in patients with cirrhosis, emphasize the need for standardized nutritional assessments, and discuss the potential impact of liver transplantation as a confounding factor.
STANDARDIZED NUTRITIONAL ASSESSMENT AND LONGITUDINAL STUDIES
Carteri et al[1] highlighted the ongoing challenge of identifying reliable nutritional predictors of survival in cirrhosis. This may be partly explained by the heterogeneity of the nutritional assessment methods used across different studies and the lack of a “gold standard” for evaluating the nutritional status in this specific population. Although various studies have investigated the association between nutritional parameters and prognosis of cirrhosis, a stepwise diagnostic approach should be followed for early recognition and management[2]. Systematic reviews and meta-analyses have demonstrated the potential benefits of nutritional support (parenteral and enteral) in improving outcomes in patients with cirrhosis and alcoholic hepatitis[3-5]. However, these studies revealed inconsistencies in the types of nutritional interventions, patient populations, and outcome measures used, highlighting the need for more standardized approaches. These protocols should incorporate both objective and subjective measures.
The American Association for the Study of Liver Diseases (AASLD) emphasized the importance of early nutritional assessment and intervention in these patients. For hospitalized patients with cirrhosis, formal consultation with a registered dietician within 24 hours of admission is recommended to assess and address malnutrition[6]. The Subjective Global Assessment (SGA) is a valuable screening tool for identifying energy malnutrition and predicting mortality in patients with cirrhosis. Miwa et al[7] demonstrated that patients classified as SGA-B or SGA-C had significantly higher odds of energy malnutrition and higher hazard ratios for mortality than those classified as SGA-A.
Low midarm muscle circumference (MAC) and reduced handgrip strength (HGS) are predictors of mortality in patients with cirrhosis, and substantial evidence supports their use in clinical practice. MAC is a predictor of mortality in patients with cirrhosis. Saueressig et al[8] demonstrated that a low MAC, defined by specific cutoff points, was associated with an increased risk of one-year mortality. In particular, severe depletion in MAC is an independent risk factor for one-year mortality, with each 1 cm increase in MAC associated with a 11% reduction in mortality risk.
Guo et al[9] found that HGS could serve as a substitute metric for muscle mass in the Global Leadership Initiative on Malnutrition criteria and was independently associated with one-year all-cause mortality in hospitalized patients with cirrhosis. Sinclair et al[10] reported that HGS added more prognostic value to the model for end-stage liver disease scores than imaging-based measures of muscle mass in men with cirrhosis.
Bioelectrical impedance analysis (BIA) can predict mortality in patients with cirrhosis. Several studies have demonstrated the prognostic value of the phase angle obtained from BIA in predicting mortality in patients with cirrhosis[11-13]. The AASLD acknowledges the use of BIA to evaluate muscle mass and nutritional status, both of which are critical factors in the prognosis of cirrhosis[6].
Recent research suggests that targeted nutritional therapy can effectively prevent the recurrence of hepatic encephalopathy (HE), a frequent and debilitating complication of cirrhosis[14]. Notably, HE has been identified as an independent predictor of mortality in patients with cirrhosis regardless of other extrahepatic organ failure[15]. Moreover, HE increases the risk of mortality and hospital readmission in decompensated patients with cirrhosis[16] and is associated with poor long-term outcomes in population-based cohorts[17], which underscore the critical need for proactive strategies to prevent and manage HE in this vulnerable population, as emphasized by the recent clinical guidelines for acute-on-chronic liver failure[18].
Furthermore, longitudinal studies aid in evaluating the long-term impact of nutritional status and interventions on clinically relevant outcomes such as survival, development of complications (including HE), need for liver transplantation, and quality of life. A multidisciplinary approach involving nutritionists and dietitians is recommended to achieve adequate protein and calorie intake[6]. While standardized nutritional assessments are essential for risk stratification, it is also important to consider the role of liver transplantation as a confounding factor in survival analyses.
IMPACT OF LIVER TRANSPLANTATION AS A CONFOUNDING FACTOR
We aimed to address the potential impact of liver transplantation on the survival outcomes observed in a study by Carteri et al[1]. Liver transplantation is a life-saving intervention that significantly improves the survival rate of patients with cirrhosis[19]. Notably, nutritional status differs between patients who underwent liver transplantation and those who did not[6,20]. However, muscle mass recovery is often incomplete, and sarcopenia may persist or increase within one year post-transplantation[21]. Malnutrition is a significant predictor of postoperative outcomes[22]. Therefore, the manner in which the authors accounted for liver transplant recipients in their analyses must be clarified. It would be helpful to determine whether patients were censored during transplantation, or if post-transplant survival was analyzed. Stratifying the analysis based on transplantation status could provide a more accurate assessment of the relationship between nutritional status and survival in the pre-transplantation and post-transplantation settings. Furthermore, certain factors, such as indications for liver transplantation, waiting time on the transplant list, and post-transplant immunosuppressive therapy, may influence nutritional status and should be considered in future analyses.
CONCLUSION
The CTP scores of patients with cirrhosis demonstrated a simple prognosis. However, the effect of nutritional management on survival in patients with cirrhosis remains unclear. Multicenter collaborative efforts and longitudinal studies to develop evidence-based guidelines for nutritional management of cirrhosis will provide robust data on the long-term impact of nutritional interventions on survival, complications, and quality of life.
