Malnutrition in cirrhosis:More food for thought

Malnutrition is highly prevalent in liver cirrhosis and its presence carries important prognostic implications.The clinical conditions and pathophysiological mechanisms that cause malnutrition in cirrhosis are multiple and interrelated.Anorexia and liver decompensation symptoms lead to poor dietary intake;metabolic changes characterised by elevated energy expenditure,reduced glycogen storage,an accelerated starvation response and protein catabolism result in muscle and fat wasting;and,malabsorption renders the cirrhotic patient unable to fully absorb or utilise food that has been consumed.Malnutrition is therefore a considerable challenge to manage effectively,particularly as liver disease progresses.A high energy,high protein diet is recognised as standard of care,yet patients struggle to follow this recommendation and there is limited evidence to guide malnutrition interventions in cirrhosis and liver transplantation.In this review,we seek to detail the factors which contribute to poor nutritional status in liver disease,and highlight complexities far greater than“poor appetite”or“reduced oral intake”leading to malnutrition.We also discuss management strategies to optimise nutritional status in this patient group,which target the inter-related mechanisms unique to advanced liver disease.Finally,future research requirements are suggested,to develop effective treatments for one of the most common and debilitating complications afflicting cirrhotic patients.

Clinical outcomes of patients with two small hepatocellular carcinomas

BACKGROUND Management of single small hepatocellular carcinoma(HCC)is straightforward with curative outcomes achieved by locoregional therapy or resection.Liver transplantation is often considered for multiple small or single large HCC.Management of two small HCC whether presenting synchronously or sequentially is less clear.AIM To define the outcomes of patients presenting with two small HCC.METHODS Retrospective review of HCC databases from multiple institutions of patients with either two synchronous or sequential HCC≤3 cm between January 2000 and March 2018.Primary outcomes were overall survival(OS)and transplant-free survival(TFS).RESULTS 104 patients were identified(male n=89).Median age was 63 years(interquartile range 58-67.75)and the most common aetiology of liver disease was hepatitis C(40.4%).59(56.7%)had synchronous HCC and 45(43.3%)had sequential.36 patients died(34.6%)and 25 were transplanted(24.0%).1,3 and 5-year OS was 93.0%,66.1% and 62.3% and 5-year post-transplant survival was 95.8%.1,3 and 5-year TFS was 82.1%,45.85% and 37.8%.When synchronous and sequential groups were compared,OS(1,3 and 5 year synchronous 91.3%,63.8%,61.1%,sequential 95.3%,69.5%,64.6%,P=0.41)was similar but TFS was higher in the sequential group(1,3 and 5 year synchronous 68.5%,37.3% and 29.7%,sequential 93.2%,56.6%,48.5%,P=0.02)though this difference did not remain during multivariate analysis.CONCLUSION TFS in patients presenting with two HCC≤3 cm is poor regardless of the timing of the second tumor.All patients presenting with two small HCC should be considered for transplantation.