Malnutrition and Nutrition Related Complaints in Liver-Transplant Candidates in Iran

Document Type : Research Paper


1 Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

2 Surgical Oncology Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

3 Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.


Introduction: the aim of this study was to evaluate the prevalence of nutrition-related complaints and malnutrition among liver transplant candidates in Iran. Methods: This cross-sectional study was conducted in two hospitals in Iran from May to October 2021. Nutritional status of patients was evaluated by subjective global assessment (SGA) and food intake of patients was assessed by 3-day food record. Also anthropometric indices, including weight and body mass index (BMI) were measured. Results: Forty-three patients were assessed. Men accounted for 58 % of patients, and mean BMI and mean age were 24.5±5 kg/m², and 48±14 years, respectively. Total prevalence of malnutrition before liver transplantation was 83.7%. In patients with malnutrition, nausea was significantly higher (P<0.05).  Low Energy intake was observed in 90.7%, while low protein intake was reported in 69.8% of patients before liver transplantation. Conclusion: Malnutrition, low calorie intake and low protein intake were prevalent among patients before liver transplantation.


  1. Mohagheghi S, Khajehahmadi Z, Nikeghbalian S, Alavian SM, Doosti-Irani A, Khodadadi I, et al. Changes in the distribution of etiologies of cirrhosis among patients referred for liver transplantation over 11 years in Iran. European journal of gastroenterology & hepatology. 2020;32(7):844-50.
  2. Traub J, Reiss L, Aliwa B, Stadlbauer V. Malnutrition in Patients with Liver Cirrhosis. Nutrients. 2021;13(2):540.
  3. Ferreira LG, Martins AIF, Cunha CE, Anastácio LR, Lima AS, Correia MITD. Negative energy balance secondary to inadequate dietary intake of patients on the waiting list for liver transplantation. Nutrition (Burbank, Los Angeles County, Calif). 2013;29(10):1252-8.
  4. Ferreira LG, Anastácio LR, Lima AS, Correia MITD. Malnutrition and inadequate food intake of patients in the waiting list for liver transplant. Revista da Associação Médica Brasileira. 2009;55:389-93.
  5. Marchesini G, Bianchi G, Lucidi P, Villanova N, Zoli M, De Feo P. Plasma ghrelin concentrations, food intake, and anorexia in liver failure. The Journal of Clinical Endocrinology & Metabolism. 2004;89(5):2136-41.
  6. Atiemo K, Skaro A, Maddur H, Zhao L, Montag S, VanWagner L, et al. Mortality risk factors among patients with cirrhosis and a low Model for End‐Stage Liver Disease sodium score (≤ 15): an analysis of liver transplant allocation policy using aggregated electronic health record data. American Journal of Transplantation. 2017;17(9):2410-9.
  7. Bunchorntavakul C, Supanun R, Atsawarungruangkit A. Nutritional status and its impact on clinical outcomes for patients admitted to hospital with cirrhosis. Journal of the Medical Association of Thailand = Chotmaihet thangphaet. 2016;99(suppl 2):S47-S55.
  8. Maharshi S, Sharma BC, Srivastava S. Malnutrition in cirrhosis increases morbidity and mortality. Journal of gastroenterology and hepatology. 2015;30(10):1507-13.
  9. Bahari H, Aliakbarian M, Norouzy A, Mansourian M, Akhavan-Rezayat K, khadem-Rezaiyan M, et al. Assessment of the nutritional status of patients before, one, and three months after liver transplantation: A multi-center longitudinal study. Clinical nutrition ESPEN. 2023;53:244-50.
  10. Lim HS, Kim HC, Park YH, Kim SK. Evaluation of Malnutrition Risk after Liver Transplantation Using the Nutritional Screening Tools. Clinical nutrition research. 2015;4(4):242-9.
  11. Tsoris A, Marlar CA. Use of the Child Pugh score in liver disease. 2019.
  12. Singal AK, Kamath PS. Model for End-stage Liver Disease. Journal of clinical and experimental hepatology. 2013;3(1):50-60.
  13. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organization technical report series. 2000;894:i-xii, 1-253.
  14. Liver EAFTSOT. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. Journal of hepatology. 2019;70(1):172-93.
  15. Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, et al. What is subjective global assessment of nutritional status? JPEN Journal of parenteral and enteral nutrition. 1987;11(1):8-13.
  16. Bischoff SC, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, et al. ESPEN practical guideline: Clinical nutrition in liver disease. Clinical nutrition (Edinburgh, Scotland). 2020;39(12):3533-62.
  17. Pirlich M, Schütz T, Spachos T, Ertl S, Weiss ML, Lochs H, et al. Bioelectrical impedance analysis is a useful bedside technique to assess malnutrition in cirrhotic patients with and without ascites. Hepatology (Baltimore, Md). 2000;32(6):1208-15.
  18. Cabre E, De Leon R, Planas R, Bertran X, Domenech E, Gassull M. Reliability of bioelectric impedance analysis as a method of nutritional monitoring in cirrhosis with ascites. Gastroenterologia Y Hepatologia. 1995;18(7):359-65.
  19. Bakshi N, Singh K. Nutrition assessment and its effect on various clinical variables among patients undergoing liver transplant. Hepatobiliary surgery and nutrition. 2016;5(4):358-71.
  20. Ferreira LG, Anastácio LR, Lima AS, Correia MI. [Malnutrition and inadequate food intake of patients in the waiting list for liver transplant]. Revista da Associacao Medica Brasileira (1992). 2009;55(4):389-93.
  21. Yadav SK, Choudhary NS, Saraf N, Saigal S, Goja S, Rastogi A, et al. Nutritional status using subjective global assessment independently predicts outcome of patients waiting for living donor liver transplant. Indian journal of gastroenterology : official journal of the Indian Society of Gastroenterology. 2017;36(4):275-81.
  22. Santos BC, Fonseca ALF, Ferreira LG, Ribeiro HS, Correia M, Lima AS, et al. Different combinations of the GLIM criteria for patients awaiting a liver transplant: Poor performance for malnutrition diagnosis but a potentially useful prognostic tool. Clinical nutrition (Edinburgh, Scotland). 2022;41(1):97-104.
  23. Merli M, Giusto M, Gentili F, Novelli G, Ferretti G, Riggio O, et al. Nutritional status: its influence on the outcome of patients undergoing liver transplantation. Liver international : official journal of the International Association for the Study of the Liver. 2010;30(2):208-14.
  24. Eghtesad S, Poustchi H, Malekzadeh R. Malnutrition in liver cirrhosis:the influence of protein and sodium. Middle East journal of digestive diseases. 2013;5(2):65-75.
  25. Topan MM, Sporea I, Dănilă M, Popescu A, Ghiuchici AM, Lupușoru R, et al. Comparison of Different Nutritional Assessment Tools in Detecting Malnutrition and Sarcopenia among Cirrhotic Patients. Diagnostics (Basel, Switzerland). 2022;12(4).
  26. Koga A, Toda K, Tatsushima K, Matsuubayashi S, Tamura N, Imamura M, et al. Portal hypertension in prolonged anorexia nervosa with laxative abuse: A case report of three patients. International Journal of Eating Disorders. 2019;52(2):211-5.
  27. Valentini L, Schuetz T, Omar A, Gläser S, Kasim E, Nowotny P, et al. Abnormal plasma peptide YY3–36 levels in patients with liver cirrhosis. Nutrition (Burbank, Los Angeles County, Calif). 2011;27(9):880-4.
  28. Tandon P, Raman M, Mourtzakis M, Merli M. A practical approach to nutritional screening and assessment in cirrhosis. Hepatology (Baltimore, Md). 2017;65(3):1044-57.
  29. Tsiaousi ET, Hatzitolios AI, Trygonis SK, Savopoulos CG. Malnutrition in end stage liver disease: recommendations and nutritional support. Journal of gastroenterology and hepatology. 2008;23(4):527-33.
  30. Anand AC. Nutrition and muscle in cirrhosis. Journal of clinical and experimental hepatology. 2017;7(4):340-57.
  31. Sinclair M, Gow PJ, Grossmann M, Angus PW. sarcopenia in cirrhosis–aetiology, implications and potential therapeutic interventions. Alimentary pharmacology & therapeutics. 2016;43(7):765-77.
  32. McClain CJ. Nutrition in patients with cirrhosis. Gastroenterology & hepatology. 2016;12(8):507.
  33. Morando F, Rosi S, Gola E, Nardi M, Piano S, Fasolato S, et al. Adherence to a moderate sodium restriction diet in outpatients with cirrhosis and ascites: a real‐life cross‐sectional study. Liver International. 2015;35(5):1508-15.
  34. Brito-Costa A, Pereira-da-Silva L, Papoila AL, Alves M, Mateus É, Nolasco F, et al. Preoperative metabolic status is associated with different evolution of resting energy expenditure after liver transplant in adults. Nutricion hospitalaria. 2017;34(5):1024-32.
  35. Ribeiro HS, Coury NC, de Vasconcelos Generoso S, Lima AS, Correia M. Energy Balance and Nutrition Status: A Prospective Assessment of Patients Undergoing Liver Transplantation. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2020;35(1):126-32.
  36. Viana ACC, Maia FMM, Carvalho NS, Morais SR, Bezerra AN, Mendonça PDS, et al. Correlation between nutritional assessment and oxidative stress in candidates for liver transplant. Einstein (Sao Paulo, Brazil). 2020;18:eAO4039.
  37. Oey RC, Aarts P, Erler NS, Metselaar HJ, Lakenman PLM, Riemslag Baas-van der Ree S, et al. Identification and prognostic impact of malnutrition in a population screened for liver transplantation. Clinical nutrition ESPEN. 2020;36:36-44.