The only treatment for end-stage liver disease (ESLD) is liver transplantation (LT) [1]. Protein energy malnutrition (PEM) is remarkably prevalent across all forms of liver disease, independent of its cause, and is common in people with ESLD [2, 3]. Malnutrition in people with ESLD has multiple causes. The etiology is complex, involving four primary causative aspects: a) reduced food intake; b) impaired absorption; c) altered metabolism; and d) additional connected factors [4]. India has a very high burden of liver disease, the country accounted for 18.3% of the two million liver disease-related deaths globally in 2015 [5].

One of the variables that has been shown to have a strong correlation with patient survival is nutritional status. Aetiology, CTP (Child Turcotte and Pugh) Scores, MELD (Model for End Stage Liver Disease) Scores, degree of ascites, blood product usage, blood loss during surgery, mortality, body composition analysis (fat mass, fat free mass, muscle mass, and body fat%), prolonged ventilator support, and longer stays in the intensive care unit and hospital have all been found to be significantly (p<0.05) correlated with malnutrition as measured by different assessment tools [3,6,7]. Due to their increased risk of malnutrition, pre-transplant patients require nutrition care to recover. In addition, the disease's catabolic nature and the patients' predominant symptoms, which impair oral intake, make it challenging to meet the patients' nutritional needs [8-10].

Even though nutrition has a critical role in the prognosis of liver disease, determining patient’s nutritional state might be difficult. Accurately determining the nutritional status of individuals with liver disease is challenging due to comorbidities such hypoproteinemia, hypoalbuminemia, and fluid retention. Subjective global assessment (SGA) has been demonstrated in studies to be an independent predictor of LT outcomes. The European Society of Enteral and Parenteral Nutrition guidelines from 2016 and 2019 recommend using simple bedside methods, such as SGA and/or anthropometry parameters, to diagnose patients with poor nutritional status and to quantify malnutrition. A lower phase angle (BIA) and weaker hand grip strength are linked to a higher mortality risk. When available, radiologic methods like DEXA or CT/magnetic resonance tomography (MRT) scans should be used to identify sarcopenia. The researchers investigated a variety of nutrition evaluation instruments to determine which ones were most suitable and easily accessible for LT patients, considering the severity of malnutrition and the difficulty in determining nutritional status. Giving ESLD patients a thorough nutritional assessment and identifying any pertinent areas for nutritional management is crucial [11].

The current study was conducted to examine the relationship between nutrition status and various parameters using SGA as a nutrition assessment instrument. This was done considering the high incidence of malnutrition among ESLD patients and its correlation with the severity and outcome of the disease [3, 12, 13].

A total of 69 adult ESLD patients (age ≥18) from a tertiary level care multispecialty hospitals in Delhi-NCR, India, participated in this exploratory study. The patients were purposively selected after taking informed consent during the January 2023-July 2023 trial period. The patients in the following group were not accepted: Patients with acute liver disease who need an emergency liver transplant. The locale selected for the study was Max Super Specialty Hospital, Saket. This study was conducted after the protocol was approved by the Institutional Scientific Committee. Ethical approval was taken from Max Healthcare Ethics Committee.

A total of 69 adult ESLD patients (age ≥18) from a tertiary level care multispecialty hospitals in Delhi-NCR, India, participated in this exploratory study. The patients were purposively selected after taking informed consent during the January 2023-July 2023 trial period. The patients in the following group were not accepted: Patients with acute liver disease who need an emergency liver transplant. The locale selected for the study was Max Super Specialty Hospital, Saket. This study was conducted after the protocol was approved by the Institutional Scientific Committee. Ethical approval was taken from Max Healthcare Ethics Committee.

Data Collection

The study comprised patients who met the inclusion and exclusion criteria. The computerized Patient Record System (CPRS) of Max Super Specialty Hospital Saket (Delhi) was used to review patient data. The following tools are used to assess the nutritional status and the different clinical parameters.

Subjective Global Assessment

SGA was executed to assess the nutrition status assessment. To obtain the patients' whole nutritional profile, the five SGA characteristics were examined. The first was weight loss over six months. A weight loss of roughly 5% or less was seen as normal, a weight loss of between 5% and 10% as potentially significant, and a weight loss of more than 10% as highly significant. Considering dietary consumption in relation to the patients' typical eating pattern was the second component. Following that, patients were classified as normal or abnormal. The extent and duration of inadequate intake were also considered. Significant gastrointestinal symptoms persisting for more than 2 weeks, such as anorexia, nausea, vomiting, and diarrhea, was the third characteristic. The patient's transition from bedridden to fully capable of carrying out everyday tasks constituted the fourth aspect. The final feature discussed the metabolic stress brought on by the underlying illness condition [14].

Assessment of Clinical Parameters

Information regarding laboratory parameters such as Hemoglobin, Albumin, Bilirubin (Total) and the grade of ascites were gathered. Information on the following blood product usage and blood loss during surgery were gathered. Handgrip Dynamometer was used to assess the muscular strength of the patients and was analyzed using cut offs by Kurniawan et al., 2018 [15]. Anthropometric measurements like present body weight (Kg), Height (cms) was gathered to compute the BMI and analyzed using WHO international and Indian Cut offs [16]. Dietary intake assessment was performed by 24-hour dietary recall [17]. Dietary recall were used for the per day consumption of calories and protein and the intake was calculated with the help of Indian Food Composition Table, 2017 [18]. The patient’s calorie and protein intake was calculated and compared to ESPEN 2020 guidelines [11, 19].

Statistical analysis

All statistical analysis was performed using MS Excel and R studio software. Categorical variables were presented as frequencies. Associations between categorical variables were evaluated through chi-square tests. Normal variables were presented as mean ± SD and were analyzed by Kruskal-Walli’s rank sum test. Patients’ intake and recommendations were assessed for difference using independent t test. An acceptable level of statistical significance was P <0.05.

Patients Profile

A total of 69 patients diagnosed with ESLD waiting for LT were included in the study. The patient profile (Table 1) undergoing LT represents 86.95% (n=60) were males and 13.04% (n= 9) were females with a mean age of 48.96 years. The data revealed that 53.73% had comorbidities, 46.37% suffered from Diabetes Mellitus, Hypertension 7.24% (n=5), Hypothyroidism 2.89% (2.89%) and kidney disease 7.24% (n=5) and 47.82 % patients had no co-morbidities.

According to SGA scores the patients were classified into the following categories: well nourished (scores: 1-7), moderately Malnourished (scores: 8-14), severely Malnourished (scores >15). Among the pre-transplant liver patients 95.65% were found to be malnourished, with 85.50% suffering from severe acute malnutrition. The data also showed that 92.7% of the patients had lower albumin levels <3.5 mg/dl indicating the need of higher requirements of protein among the pre-LT patients.  The data depicted that 95% of the males had muscle strength <28kg and 33.34% of the females had muscle strength <18 Kg according to the cut-offs suggested by Kurniawan et al., 2018 [15].

Association of Nutrition Status with Various Factors

The present data showed a significant association of malnutrition with muscle strength. The data in table 2 showed lower muscle strength among patients with higher grades of malnutrition (p=0.048). The study also assessed the association between nutrition status and blood parameters like hemoglobin, albumin levels and bilirubin levels, the data showed that lower hemoglobin and albumin levels among malnourished patients, though the results weren’t significant. Table 3 showed that significantly higher grades of ascites among malnourished patients (p<0.05).

Association of Nutrition Status with Blood Product Usage during Transplantation

Previous studies have shown that malnourished patients with ESLD are thought to need more blood products, such as packed red blood cell (PRBC) units, cryoprecipitate units, and plasma. The Kruskal-Wallis statistical test was used to examine blood units consumed and blood loss during the transplantation among various grades of nutrition status by SGA. In comparison to normal patients, malnourished patients required significantly more PRBC units during surgery (p<0.05). The data also revealed that malnourished patients had significantly higher blood loss during surgery compared to normal patients, (p<0.01) (table 4).

Energy and Protein Intake of Pre-LT Patients

ESPEN 2020 provided guidelines for liver disease and liver transplantation and recommends levels of calorie and protein for pre-transplant patients. In the pre-transplant phase, the patient’s diets were assessed for energy, protein, and other nutrient intake and compared with ESPEN 2020 guidelines for liver disease and liver transplantation, which provided recommendations for energy, protein. In the present study, one day 24-hour dietary recall was performed when the patients were admitted prior to LT, to assess the dietary intake and these were converted to energy, protein and other nutrients using the Indian Food Composition tables by Indian Council Medical Research (ICMR) 2017 [18]. The data when compared to the average of calorie and protein recommendations by ESPEN guidelines 2020 [19]. showed a significantly lower calorie and protein intake among Pre-LT recipients (Table 5). Earlier studies have also shown patients with ESLD are characterized by hypermetabolism and malnutrition due to abnormal nutrient and caloric intake, decreased intestinal absorption, and metabolic disturbances, which is associated with poor outcomes [20].

Nutrition management holds a crucial role in the treatment of liver failure before liver transplant [21,22] Previous studies exhibited a higher prevalence of malnutrition among patients undergoing LT and have identified malnutrition as an independent risk factor for poor outcomes of LT [23,24]. This study aimed to assess the association of nutrition status of pre-LT recipients with various clinical parameters. SGA is considered as a gold stand in assessing malnutrition, especially among hospitalized patients [19, 25]. SGA had shown moderate agreement with phase angle of the body (κ=0.444) among various other nutrition assessment methods and was associated with various clinical and prognostic variables of patients undergoing LT [3]. Considering the high prevalence of malnutrition and gradual deterioration of ESLD patient condition [26, 27] it is important to acknowledge and rectify various nutritional complications in ESLD [10, 28]. Which can be attained by an in-depth nutritional assessment using SGA. The present study showed 85.5% of the patients were severely malnourished (Table 1).

Table 1: Demographic profile of patients.

As a primary symptom of liver illness, the degree and severity of ascites have been associated with malnutrition in ESLD patients. [7, 29] The data in the present study also showed higher grades of ascites among pre-LT patients was associated with malnutrition (Table 3). Malnourished patients had considerably lower hemoglobin and albumin levels though it did not exhibit any discernible differences in any test parameters (Table 2). Hence, it is evident that there is need of larger study design to establish any significant associations between malnutrition and biochemical parameters among ESLD patients.

Table 2: Association of malnutrition with muscle strength and blood parameters.

Table 3: Association of malnutrition with ascites.

Handgrip strength (HGS) dynamometry is a potential technique for the diagnosis of sarcopenia and for the ongoing monitoring of muscle function in patients with cirrhosis due to its low cost, reproducibility, and safety [3, 30]. The present showed higher grade of sarcopenia among pre-LT patients (table 1) as they had lower HGS. The data also revealed that patients identified as malnourished by SGA among pre-LT patients were associated with lower muscle strength (table 2).

The patients with ESLD are thought to need more blood products, such as packed red blood cell (PRBC) units, cryoprecipitate units, and plasma [3,23,31]. The Kruskal-Wallis statistical test was used to examine blood units consumed and blood loss during the procedure using a variety of nutrition evaluation techniques. In comparison to normal patients, malnourished patients required significantly more PRBC units during surgery (p<0.05). Malnourished patients had considerably higher blood loss during surgery compared to normal patients (Table 4).

Table 4: Association of malnutrition with blood unit’s usage.

One of the major factors for malnutrition among Pre-LT patients is reduced intake. Ascites-related early satiety, an increase in Resting Energy Expenditure (REE) before to paracentesis, and dietary restrictions such minimal sodium and fluid intake, which might affect food palatability, are some potential causes of low intake [20, 32]. As far as we know, very few studies provides information regarding how several nutrition-related elements, such as appetite, calorie intake, dietary supplements, and guidance to enhance intake, are affected by patient’s nutritional intake. The present data in (Table 5) showed significantly lower intake of energy and protein among pre-LT patients than the ESPEN 2020 guidelines19 (p<0.05).

Table 5: Energy and protein intake of patients in Pre-Transplant Phase.

According to the study, there is a substantial correlation between malnutrition and increased blood loss, reduced muscle strength, and an increased requirement of blood products after surgery. It also revealed a markedly reduced energy and protein consumption prior to LT, which may provide a significant challenge to patients' post-LT recovery. To provide better care and promote overall welfare, the study emphasizes the urgent need for nutritional intervention that focuses on improving the nutritional condition for better surgery outcomes.

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