Estado nutricional, balanço energético e evolução clínica de pacientes no perioperatório de transplante hepático

Abstract

Patients with advanced liver disease waiting for liver transplantation (LT) commonly present with nutritional status and energy balance (EB) disorders before and after the operation. Poor nutritional status may negatively impact morbidity and mortality of these patients. The objective of this study was to evaluate different nutritional assessment parameters to predict clinical outcomes in the pre-transplant period; and to evaluate the evolution of the nutritional status and EB after LT. Also, it was our goal to evaluate if these changes impact time of hospitalization (in the intensive unit care - ICU; and in the hospital) and the morbi-mortality of these patients. In the preoperative and early post-transplantation, nutritional status was evaluated by Subjective Global Assessment (SGA), anthropometry (mid-arm circumference - MAC, tricipital skin fold - TSF and mid-arm muscle arm - MAMA), handgrip strength (HGS) , 6-minute walk test (6MWT) and standardized phase angle (SPA). Resting energy expenditure (REE) was measured by indirect calorimetry, dietary intake was estimated by food record, and EB was calculated. Pre-transplant clinical outcomes comprised complications of cirrhosis and mortality, and after the operation, length of ICU and hospital stay, presence of postoperative complications and mortality. These variables were drawn from the patient's medical records. Univariate and multivariate analysis as well as the ROC curve were carried out, and a p <0.05 was considered statistically significant. In the pre-transplant period, 73 patients on the waiting list for LT were evaluated, mean age of 52.3 ± 11.4 years, 63.0% were men. Low values of MAMA, malnutrition by SGA + inadequate MAMA (P <0.001), and malnutrition by SGA + low SPA (p <0.001) were independent predictors of complications of cirrhosis. SGA + SPA resulted in greater area under the curve (AUC: 0.6431). Low MAC values (p = 0.037) and slower gait in the 6MWT (GS-6MWT) (p = 0.017) were predictors of mortality, evaluated either alone or associated with SGA. SGA + GS-6MWT had higher mortality predictive power (AUC: 0.6673). Twenty-nine patients of the 73 assessed pre-transplant were followed up in the early post-transplantation. These patients had a mean age of 54.1 ± 11.5 years and 79.3% were men. The median pre-transplant evaluation time was 79.5 (IQR: 15.6 - 160.3) days before LT; the first evaluation after the operation occurred 2.4 ± 1.2 days and, the second 8.1 ± 2.8 days after LT. The mean values of MAC,TSF, MAMA, HGS and SPA significantly decreased after the operation (p <0.05). Most of the patients (71.4% and 77.8%) presented negative energy balance both pre- and post-transplantation, respectively (p < 0.05). Dietary intake, energy balance, and macronutrient intake were significantly different between the assessed times. Low values of MAMA, HGS and SPA were associated with the clinical outcomes after LT (p <0.05). Low protein intake, low REE and EB values were also associated with negative outcomes (p <0.05). In conclusion, different nutritional assessment parameters (associated or not to SGA) and negative EB were associated with clinical outcomes before and after LT. These results highlight the importance of nutritional evaluation and monitoring before and after liver transplantation, suggesting the importance of performing an early and individualized nutritional intervention in order to avoid poor clinical outcomes in this population.