Elsevier

Journal of Hepatology

Volume 40, Issue 2, February 2004, Pages 228-233
Journal of Hepatology

Weight gain after transjugular intrahepatic portosystemic shunt is associated with improvement in body composition in malnourished patients with cirrhosis and hypermetabolism

https://doi.org/10.1016/j.jhep.2003.10.011Get rights and content

Abstract

Background/Aims: To search for changes in body composition and energy metabolism associated with the repeatedly observed weight gain of cirrhotic patients after portosystemic shunting.

Methods: Twenty-one patients were studied prospectively before and 6 and 12 months after transjugular intrahepatic portosystemic shunt (TIPS) to assess body cell mass by two independent methods (total body potassium counting: body cell mass determined by TBP, BCMTBP, bioelectric impedance analysis: body cell mass determined by BIA, BCMBIA), muscle mass (anthropometry), resting energy expenditure (REECALO) by indirect calorimetry, and nutritional intake by dietary recall analysis.

Results: Prior to TIPS patients were hypermetabolic in terms of measured vs. predicted REE (REECALO median 1423 (range 1164–1838) vs. REEPRED 1279 (1067–1687) kcal; P<0.05) and their body cell mass was lower (19.1 (10.9–33.4) vs. 31.7 (16.8–47.1) kg; P=0.001). After TIPS body cell mass (BCMBIA) increased to 23.5 (12.7–44.3) (P<0.025) and 25.7 (14.2–39.7) kg (P=0.05) at 6 and 12 months after TIPS and this was confirmed by total potassium counting (BCMTBP before TIPS: 18.8 (10.6–26.7) vs. 22.4 (12.9–28.5) kg at 6 months; P<0.01). Hypermetabolism persisted throughout the study period. Energy and protein intake increased significantly by 26 and 33%.

Conclusions: An increase of prognostically relevant variables body cell and muscle mass contributes to the weight gain after TIPS in malnourished patients with cirrhosis and hypermetabolism.

Introduction

Protein energy malnutrition is a frequent consequence of hepatic cirrhosis which puts patients at a higher risk of complications [1], death [2], [3], [4], and a complicated course after liver transplantation including death [5], [6]. After successful treatment of portal hypertension by surgical or interventional shunt procedures weight gain and improvement in the nutritional status have been reported repeatedly [7], [8], [9], [10]. In cirrhosis, however, the precise assessment of nutritional state is complicated by water retention [11]. Recently, Selberg and coworkers [6] found that the reduction in preoperative body cell mass was a relevant predictor of a less favourable outcome of liver transplantation.

In a prospective study we therefore assessed the evolution of body composition, energy expenditure, nutrient intake, as well as mental state over periods of 6 and 12 months after a transjugular intrahepatic portosystemic stent-shunt (TIPS) had been inserted [12]. As a reference body cell mass estimated by bioelectrical impedance analysis and resting energy expenditure were determined in healthy controls, too. Specifically, we were interested to see: (1) whether the weight gain following TIPS was associated with an increase in the metabolically relevant compartments muscle mass or body cell mass as assessed by two independent methods; and (2) whether patients with TIPS do tolerate a diet according to the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines [1] without adverse effects on mental state.

Section snippets

Patients

Twenty-one patients (13 men, eight women; age: 60.0 (38.7–71.6) years) with liver cirrhosis of alcoholic (n=19) or non-alcoholic (one autoimmune hepatitis, one primary biliary cirrhosis) origin were studied prospectively before and 6.0 (5.0–7.4) months as well as 12.5 (11.8–14.9) months after TIPS insertion. The indications for TIPS insertion were recurrent esophageal variceal bleeding in 14 patients (nine without ascites and five with ascites) and refractory ascites in seven patients. The

Results

TIPS was well tolerated by all patients. Among the 14 patients in whom TIPS was performed for treatment of variceal hemorrhage, there was one episode of variceal bleeding within the first 6 months and one at month 9 due to TIPS occlusion which required a surgical shunt procedure as compared to 4 (0–10) episodes in the year prior to TIPS (P<0.001) and ascites was absent (n=4) or moderate (n=1) in the five patients who also had ascites prior to TIPS. Ascites improved significantly in all seven

Body composition

In this prospective study we demonstrated that body cell mass in patients with liver cirrhosis is severely reduced and this condition does not inevitably run a downhill course but can be ameliorated as demonstrated in a patient cohort treated with TIPS. Using three independent methods (anthropometry, bioelectrical impedance analysis, total body potassium counting) to analyse body composition we could not only confirm the repeatedly claimed improvement in nutritional state after successful

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