Spotlight on cirrhosis

Patients with cirrhosis were the focus of several recent studies, which reviewed the evidence behind nutritional assessment, calculated the cost-effectiveness of hepatocellular carcinoma screening, and estimated the prevalence of nonalcoholic steatohepatitis-associated cirrhosis.


Patients with cirrhosis were the focus of several recent studies, which reviewed the evidence behind nutritional assessment, calculated the cost-effectiveness of hepatocellular carcinoma screening, and estimated the prevalence of nonalcoholic steatohepatitis (NASH)-associated cirrhosis.

The review article, published online on Feb. 6 by Hepatology, proposes an algorithm for nutritional screening in patients with cirrhosis.

The authors used a combination of evidence in the literature, practice guidelines, and clinical experience to inform their approach. They suggest that patients with cirrhosis with a body mass index (BMI) less than 18 kg/m2 or a Child-Pugh score of C receive a detailed nutritional assessment. Such an assessment would include a review of inflammation and cirrhosis severity, dietary intake and possible barriers, weight loss and BMI, and any changes in muscle mass or function. The algorithm suggests implementing a nutritional management plan if necessary.

To rapidly screen for malnutrition in other patients with cirrhosis, clinicians should use the Royal Free Hospital-Nutritional Prioritizing Tool, the algorithm suggests. If the resulting score is between 2 and 7, perform a detailed nutritional assessment and implement a nutritional management plan if necessary. If not, repeat the screen weekly while the patient is hospitalized and every one to six months when he or she is evaluated as an outpatient, the algorithm suggests.

“Although common sense indicates that adoption of even the minimal elements of nutrition screening and assessment outweighs the issues associated with the absence of validated tools and consensus in this area, there is still much room for refinement,” the authors wrote, noting the need for future research on the implications of sex, volume status, inflammation, and obesity.

Another study in Hepatology, published online on Feb. 8, compared the cost-effectiveness of guideline-recommended surveillance (“gold-standard monitoring”) versus real-life monitoring of hepatocellular carcinoma in patients with cirrhosis.

Using a Markov model, researchers used two French cohorts (CirVir and CHANGH) to derive probabilities of disease progression and calculate costs. Gold-standard monitoring included following guidelines for screening patients beginning at 55 years of age with compensated cirrhosis for hepatocellular carcinoma, whereas real-life monitoring was defined as what is observed in real life in terms of incidence, survival, and costs associated with cirrhosis and hepatocellular carcinoma.

Overall, mean survival increased by 0.37 year with gold-standard monitoring compared to real-life monitoring (7.18 vs. 6.81 years). The cost difference between groups was $11,965 ($93,795 in the gold-standard monitoring group vs. $81,829 in the real-life monitoring group) in the U.S. and $648 ($87,476 vs. $86,829) in France. Gold-standard monitoring in this patient population was deemed cost-effective, with incremental cost-effectiveness ratios of $32,415 per life-year gained in the U.S. and $1,754 per life-year gained in France.

The authors noted that the large difference between the U.S. and French efficiency ratios is due to the four- to 10-fold difference in unit costs for surveillance (e.g., clinic visits, tests) and for first-line curative treatments, respectively. They added that a five-month gain in life expectancy may seem modest but is good by cancer-screening standards. A limitation is that the two cohorts used to estimate disease progression probabilities enrolled patients with varying types of cirrhosis (e.g., viral in CirVir vs. all types in CHANGH), they added.

Finally, a prevalence study of NASH cirrhosis in the U.S. was published online on Feb. 14 by The American Journal of Gastroenterology.

Using data from the National Health and Nutrition Examination Survey, researchers found that the prevalence of NASH cirrhosis increased 2.5-fold and nonalcoholic fatty liver disease-associated advanced fibrosis increased 2-fold in 2009 to 2012 compared to 1999 to 2002.