Cassandra Picinbono-Larose

Malnutrition in chronic liver disease: Implications for quality of life and hepatic encephalopathy

Cassandra Picinbono-Larose, Annie Lamoussenerie, Mélanie Tremblay, Catherine Vincent, Geneviève Huard, Christopher Rose, Chantal Bémeur.

BACKGROUND: Malnutrition is the most common complication in patients with chronic liver disease (CLD) and may increase the risk of developing hepatic encephalopathy (HE) as well as affect pa-tients’ functional status and quality of life (QOL). Management strategies focussing on nutritional status in relation to complications of CLD are an unmet clinical need. PURPOSE: The objectives are to: 1) Assess nutri-tional status and its relationship to QOL; 2) Ascer-tain the presence, severity and history of HE; 3) Inquire the relationship of HE and history of HE on the QOL of CLD subjects. METHOD: Observational and cross-sectional study involving 50 patients (hospitalized and outpatients) from the CHUM’s Liver Unit, Montreal, Canada) and 18 controls (non-cirrhotic). All subjects were assessed for: 1) Nutritional Status: Standardized Questionnaire Subjective Global Assessment (SGA); 2) QOL: General questionnaire SF-36 evalu-ating the QOL as perceived by the patient (8 scales: physical functioning (PF), role limitations due to physical health (RP), due to emotional problems (RE), social functioning (SF), bodily pain (BP), vitality (VT), mental health (MH) and general health (GH)); 3) HE: History and presence of covert HE using EncephalApp Stroop test or overt HE using the Clinical Hepatic Encephalopathy Staging Scale.RESULT(S): 50 CLD patients (72% men) of various etiologies (18% NASH, 12% alcoholic, 8% autoim-mune, 6% viral, 12% others and 44% mixed eti-ologies), Child–Pugh (15A, 7B, 18C and 10 N/A), aged 56±12 years and 18 non-cirrhotic patients (33% male, aged 42±15). SGA revealed that 34% of CLD subjects were malnourished. Among mal-nourished CLD patients, 18% were diagnosed with covert or overt HE. CLD malnourished patients had a lower perception of QOL than well-nour-ished CLD patients for all SF-36 scales (p < 0.01). History of HE was associated with poor QOL as CLD patients with a history of HE (36%) showed decreased PF (p = 0.024) and RP (p < 0.01). Com-pared to controls, CLD patients displayed a lower score in PF (p < 0.05) and GH (p < 0.05).CONCLUSION(S): Our data suggest that a subop-timal nutritional status based on SGA negatively affects 6 scales out of 8 of QOL (RP, RE, SF, VT, MH and GH) but is not associated with presence of HE. However, history of HE does impact two scales of QOL (PF and RP). Identifying malnourished CLD patients is of great importance to improve QOL. Interventions to prevent and treat malnutrition in CLD remain a primary need.

Nutritional status in patients with chronic liver disease: Impact on hepatic encephalopathy and health-related quality of life.

Cassandra Picinbono-Larose, Annie Lamoussenerie, Mélanie Tremblay, Catherine Vincent, Geneviève Huard, Christopher F. Rose, Chantal Bémeur.

Introduction: Malnutrition is an important prognostic factor potentially influencing clinical outcome of patients suffering from chronic liver disease (CLD; cirrhosis) and may increase the risk of developing other complications including hepatic encephalopathy (HE). Malnutrition in cirrhosis may also affect patient’s functional status and health-related quality of life (HRQOL). Management strategies focussing on nutritional status in relation to complications of cirrhosis are an unmet clinical need. We hypothesize that sub-optimal nutritional status in cirrhotic patients increases the risk of developing HE and decreases HRQOL. Objectives: The primary goal is to evaluate the impact of nutritional status on health-related quality of life in cirrhotic patients. The secondary goal is to ascertain the presence of HE and examine its relationship with nutritional status and HRQOL. Methods: Hospitalized and outpatients with cirrhosis as well as non-cirrhotic (NC) patients were assessed for 1) Nutritional status (SGA); 2) HE; 3) HRQOL (SF-36). Results: 50 cirrhotic patients (72% men) of various etiologies as well as 18 NC patients (33% men) were included. SGA analysis revealed that 34% of cirrhotic patients were malnourished whereas 12% of cirrhotic patients were diagnosed with HE at time of recruitment and 37% had a history of HE. Among malnourished CLD patients, 18% were diagnosed with HE. CLD malnourished patients showed a decreased HRQOL compared to well-nourished CLD patients (p<0,01). Moreover, HE had an impact on HRQOL as cirrhotic patients with a history of HE episode(s) showed decreased physical functioning (p=0,024) and role limitations due to physical health (p=0,002). Interestingly, when compared to NC patients, CLD patients displayed a lower score in physical functioning (p<0,0001) and general health (p=0,027). Conclusion: Our data suggest that poor nutritional status and history of HE episode(s) do negatively influence HRQOL in cirrhotic patients. Significance: Our study provides important results in order to empower the field of dietitics to actively engage in malnutrition management in cirrhosis.

Impact de l'état nutritionnel sur la qualité de vie et l'encéphalopathie hépatique lors de maladies chroniques du foie.

Cassandra Picinbono-Larose, Annie Lamoussenerie, Mélanie Tremblay, Catherine Vincent, Geneviève Huard, Christopher F. Rose, Chantal Bémeur.

Nutritional status, hepatic encephalopathy and health-related quality of life in patients with chronic liver disease.

Christopher F. *Rose, Cassandra Picinbono-Larose, Annie Lamoussenerie, Mélanie Tremblay, Catherine Vincent, Geneviève Huard, Christopher F. Rose, Chantal Bémeur.

Background: Malnutrition is an important prognostic factor potentially influencing clinical outcome of patients suffering from chronic liver disease (CLD; cirrhosis) and may increase the risk of developing other complications including hepatic encephalopathy (HE). Malnutrition in cirrhosis may also affect patient’s functional status and health-related quality of life (HRQOL). Management strategies focussing on nutritional status in relation to complications of cirrhosis are an unmet clinical need. We hypothesize that sub-optimal nutritional status in cirrhotic patients increases the risk of developing HE and decreases HRQOL. Purpose: The primary purpose is to evaluate the impact of nutritional status on health-related quality of life in cirrhotic patients. The secondary purpose is to ascertain the presence of hepatic encephalopathy and examine its relationship with nutritional status and HRQOL. Method: Hospitalized and outpatients (CHUM’s Liver Unit, Montreal, Canada) with cirrhosis as well as non-cirrhotic (NC) patients were assessed for 1) Nutritional status (Subjective Global Assessment (SGA)); 2) HE (presence or history); 3) HRQOL (Short-Form-36 (SF-36) questionnaire). Results: 50 cirrhotic patients (72% men) of various etiologies, Child-Pugh (15A, 7B, 18C, 10 unknown), mean age 56±12 as well as 18 NC patients (33% men, mean age 42±15) were included. SGA analysis revealed that 34% of cirrhotic patients were malnourished whereas 12% of cirrhotic patients were diagnosed with HE at time of recruitment and 37% had a history of HE. Among malnourished CLD patients, 18% were diagnosed with HE. CLD malnourished patients showed a decreased HRQOL compared to well-nourished CLD patients (p<0,01). Moreover, HE had an impact on HRQOL as cirrhotic patients with a history of HE episode(s) showed decreased physical functioning (p=0,024) and role limitations due to physical health (p=0,002). Interestingly, when compared to NC patients, CLD patients displayed a lower score in physical functioning (p<0,0001) and general health (p=0,027). Conclusion: Our data suggest that poor nutritional status does negatively influence HRQOL in cirrhotic patients but is not associated with HE. However, history of HE episode(s) does impact on HRQOL among this population. Therefore, identifying malnourished patients is of great importance and interventions for treating malnutrition remains an unmet clinical need.

Nutritional status, hepatic encephalopathy and health-related quality of life in patients with chronic liver disease.

Cassandra Picinbono-Larose, Annie Lamoussenerie, Mélanie Tremblay, Catherine Vincent, Geneviève Huard, Christopher F. Rose, Chantal Bémeur.

Background: Malnutrition is an important prognostic factor potentially influencing clinical outcome of patients suffering from chronic liver disease (CLD; cirrhosis) and may increase the risk of developing other complications including hepatic encephalopathy (HE). Malnutrition in cirrhosis may also affect patient’s functional status and health-related quality of life (HRQOL). Management strategies focussing on nutritional status in relation to complications of cirrhosis are an unmet clinical need. We hypothesize that sub-optimal nutritional status in cirrhotic patients increases the risk of developing HE and decreases HRQOL. Purpose: The primary purpose is to compare the nutritional status of adult patients with cirrhosis to non-cirrhotic patients. The secondary purposes is to ascertain hepatic encephalopathy (current and previous history) and quality of life among this population. Method: Hospitalized and outpatients (CHUM’s Liver Unit, Montreal, Canada) with cirrhosis as well as non-cirrhotic (NC) patients were assessed for 1) Nutritional status (Subjective Global Assessment (SGA)); 2) HE (presence or history); 3) HRQOL (Short-Form-36 (SF-36) questionnaire). Results: 50 cirrhotic patients (72% men) of various etiologies, Child-Pugh (15A, 7B, 18C, 10 unknown), mean age 56±12 as well as 18 NC patients (33% men, mean age 42±15) were included. SGA analysis revealed that 34% of cirrhotic patients were malnourished whereas 12% of cirrhotic patients were diagnosed with HE at time of recruitment and 37% had a history of HE. Among malnourished CLD patients, 18% were diagnosed with HE. CLD malnourished patients showed a decreased HRQOL compared to well-nourished CLD patients (p<0,01). Moreover, HE had an impact on HRQOL as cirrhotic patients with a history of HE episode(s) showed decreased physical functioning (p=0,024) and role limitations due to physical health (p=0,002). Interestingly, when compared to NC patients, CLD patients displayed a lower score in physical functioning (p<0,0001) and general health (p=0,027). Conclusion: Our data suggest that poor nutritional status does negatively influence HRQOL in cirrhotic patients but is not associated with HE. However, history of HE episode(s) does impact on HRQOL among this population. Therefore, identifying malnourished patients is of great importance and interventions for treating malnutrition remains an unmet clinical need.

Comparison of nutritional assessment tools in cirrhotic patients.

Annie Lamoussenerie, Cassandra Picinbono-Larose, Mélanie Tremblay, Thierry Cresson, Catherine Vincent, Geneviève Huard, Christopher F. Rose, Chantal Bémeur.

Oral

Hepatic encephalopathy and health-related quality of life among cirrhotic patients: Scope of nutritional status.

Cassandra Picinbono-Larose, Annie Lamoussenerie, Mélanie Tremblay, Catherine Vincent, Geneviève Huard, Christopher Rose, Chantal Bémeur.

Malnutrition is an important prognostic factor potentially influencing clinical outcome of patients suffering from chronic liver disease (cirrhosis; CLD). Malnutrition may increase the risk of developing other complications including hepatic encephalopathy (HE). Malnutrition in cirrhosis may also affect patient’s functional status and health-related quality of life (HRQOL). Management strategies focussing on nutritional status in relation to complications of cirrhosis are an unmet clinical need. We hypothesize sub-optimal nutritional status in cirrhotic patients increases the risk of developing HE and decreases HRQOL. Hospitalized and outpatients (CHUM’s Liver Unit in Montreal, Canada) with liver cirrhosis of different etiologies and healthy controls were assessed for 1) Nutritional status (Subjective Global Assessment (SGA)); 2) HE (Clinical HE Staging Scale (CHESS)); 3) HRQOL (Short-Form-36 (SF-36) questionnaire). This on-going prospective study included 33 cirrhotic patients (58% men) of various etiologies (% : 30 alcohol, 33 virus, 27 NASH and 33 others), Child-Pugh (13A, 9B, 5C and 6N/A), mean age 55,7±12,9 as well as 13 healthy controls (46% men, mean age 49,4±14,9). SGA analysis revealed that 27% of cirrhotic patients were malnourished. Furthermore, cirrhotic malnourished patients show decreased HRQOL compared to well-nourished cirrhotic patients (p<0.01). Cirrhotic patients, when compared to controls, displayed a lower score in physical functioning (p=0.03) and general health (p=0.03). CHESS analysis revealed none of the cirrhotic patients had HE while 21% of them had an HE diagnosis in medical chart, suggesting CHESS would not be sensible enough to screen HE. Our preliminary results suggest that nutritional status does influence particular domains of HRQOL in cirrhotic patients irrespective of their etiology. Further patients are required to statistically confirm the impact of nutritional status on HE and HRQOL in cirrhotic patients. Identifying factors associated with nutritional status, HRQOL and HE in cirrhotic patients may help improve patient care and guide future research.

Impact de l’état nutritionnel sur l’encéphalopathie hépatique et la qualité de vie chez les patients atteints de maladie chronique du foie : Résultats préliminaires d’une étude prospective.

Cassandra Picinbono-Larose, Annie Lamoussenerie, Mélanie Tremblay, Catherine Vincent, Geneviève Huard, Christopher F. Rose, Chantal Bémeur.

Comparaison d’outils d’évaluation nutritionnelle lors de cirrhose.

Annie Lamoussenerie, Cassandra Picinbono-Larose, Mélanie Tremblay, Thierry Cresson, Catherine Vincent, Geneviève Huard, Christopher F. Rose, Chantal Bémeur.

Oral

Impact de l'état nutritionnel sur l'encéphalopathie hépatique et la qualité de vie chez les patients atteints de maladie chronique du foie: résultats préliminaires d'une étude prospective.

Cassandra Picinbono-Larose, Annie Lamoussenerie, Mélanie Tremblay, Catherine Vincent, Geneviève Huard, Christopher Rose, Chantal Bémeur.

Nutritional status assessment in patients with chronic liver disease: a pilot study.

Annie Lamoussenerie, Cassandra Picinbono-Larose, Mélanie Tremblay, Catherine Demers, Catherine Vincent, Geneviève Huard, Christopher F. Rose, Chantal Bémeur.

Impact of nutritional status on hepatic encephalopathy and quality of life in patients with chronic liver disease: preliminary results of a prospective study.

Cassandra Picinbono-Larose, Annie Lamoussenerie, Mélanie Tremblay, Catherine Demers, Catherine Vincent, Geneviève Huard, Christopher F. Rose, Chantal Bémeur.

Background: Malnutrition is an important prognostic factor potentially influencing clinical outcome of patients suffering from chronic liver disease (cirrhosis; CLD). Malnutrition may increase the risk of developing other complications including hepatic encephalopathy (HE). Malnutrition in cirrhosis may also affect patient’s functional status and wellbeing or health-related quality of life (HRQOL). Management strategies focussing on nutritional status in relation to complications of cirrhosis are an unmet clinical need. We hypothesize sub-optimal nutritional status in cirrhotic patients increases the risk of developing HE and decreases HRQOL. Methods: 33 patients (outpatients and hospitalized; CHUM’s Liver Unit in Montreal, Canada) with liver cirrhosis of different etiologies and 13 healthy controls were assessed for 1) Nutritional status (Subjective Global Assessment (SGA)); 2) HE (Clinical HE Staging Scale (CHESS)); 3) HRQOL (Short-Form-36 (SF-36) questionnaire). Results: This on-going prospective study included 33 cirrhotic patients (58% men) of various etiologies (30% alcohol, 33 % virus, 27% NASH and 33% others), Child-Pugh A/B/C (13A, 9B, 5C and 6 N/A), mean age 55,7±12,9 as well as 13 healthy controls (46% men, mean age 49,4±14,9). SGA analysis revealed that 27% of cirrhotic patients were malnourished in which 22% of them malnourished showed signs of HE as assessed by CHESS. Cirrhotic patients, when compared to controls, displayed a lower score in physical functioning (p=0.03) and general health (p=0.03), both part of the physical health domain of SF-36. Furthermore, cirrhotic malnourished patients show decreased physical aspects of HRQOL compared to well-nourished cirrhotic patients (p<0.01). Conclusion: Our preliminary results suggest that nutritional status does influence particular domains of HRQOL in cirrhotic patients irrelevant of their etiology. Further patients are required to statistically confirm the impact of nutritional status on HE and HRQOL in cirrhotic patients. Identifying factors associated with nutritional status, HRQOL and HE in cirrhotic patients may help improve patient care and guide future research.

Cassandra Picinbono-Larose, Dt.P., M.Sc.

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