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Impact of Liver and Pancreas Diseases on Nutritional Status

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Impact of Liver and Pancreas Diseases on Nutritional Status nutrients Review Impact of Liver and Pancreas Diseases on Nutritional Status Pablo Cañamares-Orbis 1, Vanesa Bernal-Monterde 2,3 , Olivia Sierra-Gabarda 2,3, Diego Casas-Deza 2,3 , Guillermo Garcia-Rayado 3,4, Luis Cortes 3,4 and Alberto Lué 1,* 1 Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge, 22004 Huesca, Spain; [email protected] 2 Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain; [email protected] (V.B.-M.); [email protected] (O.S.-G.); [email protected] (D.C.-D.) 3 Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; [email protected] (G.G.-R.); [email protected] (L.C.) 4 Service of Digestive Diseases, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain * Correspondence: [email protected]; Tel.: +34-974-247-000 (ext. 524158) Abstract: Liver and pancreatic diseases have significant consequences on nutritional status, with direct effects on clinical outcomes, survival, and quality of life. Maintaining and preserving an ade- quate nutritional status is crucial and should be one of the goals of patients with liver or pancreatic disease. Thus, the nutritional status of such patients should be systematically assessed at follow- up. Recently, great progress has been made in this direction, and the relevant pathophysiological mechanisms have been better established. While the spectrum of these diseases is wide, and the mechanisms of the onset of malnutrition are numerous and interrelated, clinical and nutritional manifestations are common. The main consequences include an impaired dietary intake, altered macro and micronutrient metabolism, energy metabolism disturbances, an increase in energy ex- penditure, nutrient malabsorption, sarcopenia, and osteopathy. In this review, we summarize the Citation: Cañamares-Orbis, P.; factors contributing to malnutrition, and the effects on nutritional status and clinical outcomes of Bernal-Monterde, V.; Sierra-Gabarda, liver and pancreatic diseases. We explain the current knowledge on how to assess malnutrition and O.; Casas-Deza, D.; Garcia-Rayado, the efficacy of nutritional interventions in these settings. G.; Cortes, L.; Lué, A. Impact of Liver and Pancreas Diseases on Nutritional Keywords: liver cirrhosis; malnutrition; malabsorption; vitamins; minerals; sarcopenia; liver transplant; Status. Nutrients 2021, 13, 1650. pancreatic exocrine insufficiency; nutritional assessment https://doi.org/10.3390/nu13051650 Academic Editor: Pietro Vajro 1. Introduction Received: 31 March 2021 Liver and pancreatic diseases have significant consequences on nutritional status. Accepted: 11 May 2021 Published: 13 May 2021 Malnutrition affects between 20% and 50% of patients with liver disease, and this rate could rise to 80% for patients with decompensated cirrhosis [1]. In chronic pancreatitis, up Publisher’s Note: MDPI stays neutral to 90% of patients have exocrine pancreatic insufficiency (EPI) twelve years after diagnosis, with regard to jurisdictional claims in 40% of patients are underweight, and 17% have sarcopenia [2–4]. Frequently, the effects on published maps and institutional affil- nutritional status remain undiagnosed until the disease is already in an advanced stage, iations. when it is challenging to manage. In the last year, the impact of malnutrition on clinical outcomes has been well estab- lished. In patients with liver cirrhosis, malnutrition increases the incidence and severity of decompensations, influences the immune response, reduces muscle mass, deteriorates functional status and quality of life, and is associated with increased mortality [5–7]. In Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. particular, malnutrition is related to the development and severity of hepatic encephalopa- This article is an open access article thy [8] and has an impact on evolution after liver transplantation [9]. In patients with distributed under the terms and pancreatic disease, malnutrition is associated with increased mortality and hospitaliza- conditions of the Creative Commons tion rates, a low quality of life, and poorer survival in patients with advanced pancreatic Attribution (CC BY) license (https:// cancer [4,10–12]. creativecommons.org/licenses/by/ Given these data, maintaining and preserving an adequate nutritional status is cru- 4.0/). cial and should be one of the goals of such patients. Recently, great progress has been Nutrients 2021, 13, 1650. https://doi.org/10.3390/nu13051650 https://www.mdpi.com/journal/nutrients Nutrients 2021, 13, 1650 2 of 25 made in this direction, and the relevant pathophysiological mechanisms have been better established. While the spectrum of these diseases is wide, and the mechanisms of the onset of malnutrition are numerous and interrelated, clinical and nutritional manifesta- tions are common. Regardless of the etiology and the organ affected, the fundamental mechanisms of malnutrition in these diseases include poor dietary intake, malabsorption of micronutrients and macronutrients, and altered metabolism [13–16]. Even if the detrimental effects of malnutrition associated with liver and pancreatic diseases are well known, the scientific knowledge of a successful strategy to correct this manifestation is controversial, and the goal of contributing to such knowledge is difficult to achieve in the clinical practice [1,17]. In this review, we aim to describe the factors contributing to malnutrition and the effects of liver and pancreatic diseases on nutritional status and determine how to assess malnutrition. Further, we summarize the current knowledge on the management of malnutrition and the efficacy of nutritional interventions in these settings. 2. Consequences of Liver Disease on Nutritional Status Liver fibrosis is the consequence of different inflammatory processes occurring in any chronic liver disease. Its progression determines the development of cirrhosis and portal hypertension. The natural history of cirrhosis is characterized by a compensated phase, with or without portal hypertension, and a decompensated phase characterized by the appearance of major complications, such as ascites, portal hypertensive bleeding, encephalopathy, and jaundice. Malnutrition is frequent in patients with liver cirrhosis, which progresses in parallel with the worsening of the disease. Its etiology is multifactorial, given the great impact of liver disease on multiple processes related to nutrition [18]. In this section, we summarize the consequences of liver disease on nutritional status, focusing on the different components and functions that might be affected throughout the course of the disease (Table1). Table 1. Consequences of liver disease on nutritional status. Nutritional Consequence [Ref.] Mechanisms in Chronic Liver Disease Anorexia, dysgeusia, abdominal pain, bloating, early satiety 1. Impaired dietary intake [19,20] secondary to ascites, prescription of restrictive diets, alcohol consumption Lack of glycogen and vitamin storage, breakdown of fat and 2. Altered macro and micronutrient metabolism [13–16,21–24] proteins as the principal energy source, decrease of vitamin and mineral levels Hypermetabolic state, impaired glucose and lipid metabolism, 3. Energy metabolism disturbances [25] sedentary lifestyle 4. Increase in energy expenditure [26,27] Increased catecholamines, malnutrition, immune compromise Decreased bile production, cholestasis, portosystemic shunting, 5. Nutrient malabsorption [28,29] portal hypertension gastropathy and enteropathy, small intestinal bacterial overgrowth, drug-related diarrhea Proteolysis as the energy source, inhibition of muscle growth, 6. Sarcopenia and muscle function [30–32] muscle autophagy, proinflammatory state Decrease in bone formation, increased bone resorption, dysbiosis, 7. Metabolic osteopathy [33] vitamin K and D deficiencies 2.1. Impaired Dietary Intake Anorexia is very common in patients with cirrhosis. It is caused by a mechanical effect, such as ascites, or by an imbalance between orexigenic and anorexigenic hormones (decrease of ghrelin and increase in leptin, respectively) [19]. Moreover, dietary restrictions imposed—sometimes quite rightly (sodium restriction for ascites) and sometimes based on false convictions (protein consumption restriction for encephalopathy)—may adversely limit dietary intake and cause taste alterations. The maintenance of an adequate nutritional status should prevail over dietary restrictions [20]. Nutrients 2021, 13, 1650 3 of 25 Regarding the etiology of liver disease, dietary intake is worse in alcoholic patients, given that alcohol represents their principal source of energy, rather than nutrient-rich foods. As a result, they develop nutrient deficiencies such as low serum levels of folate (B9), cobalamin (B12), and pyridoxine (B6), as well as macronutrient deficiencies. 2.2. Altered Macro and Micronutrients Metabolism 2.2.1. Plasma Proteins Hepatocytes play a central role in the production of plasma proteins, and the liver is the site where 80% of blood proteins are formed, except for gamma-globulin, which is produced by the reticuloendothelial system in the Kupffer cells. Plasma proteins include albumin (55%), globulins (38%), and fibrinogen (7%). They also include clotting factors, carrier and transport proteins, hormones, apolipoproteins, and other proteins involved in homeostasis. Albumin is the principal plasma protein and modulator of the fluid distribution in compartments of the body, accounting for about
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