Elsevier

Nutrition

Volume 27, Issue 3, March 2011, Pages 282-286
Nutrition

Applied nutritional investigation
Subjective global assessment is not sufficient to screen patients with defective hepatic metabolism

https://doi.org/10.1016/j.nut.2009.10.016Get rights and content

Abstract

Background and aims

Subjective global assessment (SGA) is useful for screening malnourished patients with several diseases, although it has been indicated to underestimate nutritional status for patients with liver disease. Accordingly, the aim of this study was to examine the usefulness of SGA as a nutritional screening tool for patients with liver disease, compared to patients with gastroenterological disease, without bias of personal ability and experience.

Methods

SGA was performed on 129 of hospitalized patients (86 with liver disease and 43 with gastroenterological disease). Nutritional status was categorized as well-nourished or malnourished status, based on nutritional indicators from laboratory data.

Results

The SGA screening ratio (sensitivity) for malnourished patients with liver disease was significantly lower than gastroenterological disease, while specificity or efficiency was not significantly different. In nutritional indicators from laboratory data, the difference between SGA-positive and SGA-negative patients with liver disease was significant but not so remarkable compared with the difference between those with other diseases. The positive number of SGA components per patient for the liver disease group was significantly less than gastroenterological disease group.

Conclusions

SGA for patients with liver diseases was not sufficient as a nutritional screening tool because malnutrition induced by defective hepatic metabolism was not characterized fully.

Introduction

Nutritional status is one of the most important factors affecting not only the quality of life (QOL) but also the prognosis of patients with liver cirrhosis [1], [2], [3], [4], [5], [6], [7]. Its importance is partly explained by the therapeutic consequences for complications induced by liver cirrhosis such as hepatocellular carcinoma or esophageal and gastric varices. When therapies for these complications are required, therapeutic indication depends on the patient's liver function and nutritional status [8]. Thus, patients with severe liver dysfunction and malnutrition cannot receive complete treatment for the complications, leading to decline of QOL and poorer prognosis. Therefore, nutritional screening and assessment of liver function are required for patients with liver cirrhosis, especially for hospitalized patients, to support the treatment of such complications.

Subjective global assessment (SGA) is used worldwide to screen malnourished patients with several diseases. SGA estimates nutritional status based on simple questions and physical findings concerning body weight, appetite, pyrexia, vomiting, diarrhea, ascites, edema, and wasting of muscle or fat [9], [10], [11], [12]. SGA has some advantages as a nutritional screening tool because of its simplicity, safety, and low cost [13], [14]. However, SGA is based on personal subjectivity [15] and therefore it is important to assess SGA without bias of personal ability and experience.

Applicability of SGA for the screening of malnourished patients with liver cirrhosis might well be questioned. SGA has been demonstrated to be useful for assessing the nutrition status of advanced cirrhotic patients [16] and adult liver-transplant candidates [12]. However, it has been demonstrated that SGA determines about 30%–50% of malnourished patients with liver cirrhosis [17], [18]. Thus, SGA may underestimate nutritional status and fail to detect malnutrition for patients with liver cirrhosis. However, applicability of SGA has never been investigated by comparing to disease control and therefore its applicability is still controversial in patients with liver cirrhosis.

The aim of this study is to investigate applicability of SGA as a nutritional screening tool for patients with liver disease, comparing them to patients with gastroenterological diseases, without bias of personal ability and experience.

Section snippets

Subjects

One hundred twenty-nine patients hospitalized in the Gastroenterological Unit of Kurume University Hospital between September 2005 and July 2006 were enrolled in this study. These patients were divided into two groups: patients with liver disease (LD; n = 86) and patients with gastroenterological disease (GD; n = 43). Liver diseases included hepatitis C virus (n = 64) and hepatitis B virus (n = 13) infection, and others (n = 9). Seventy-five patients with hepatocellular carcinoma were seen among the 83

Background and nutritional status of all patients

As shown in Table 1, the mean age and the prevalence of patients with neoplasm in the LD group were significantly higher than in the GD group, while distribution of gender was not significantly different. Although these data suggested higher risk of malnutrition in the LD group than in the GD group, distribution of nutritional status was not significantly different between LD and GD groups in all three models.

Screening ratio of SGA

The screening ratio for malnourished patients, identical to sensitivity, in the LD

Discussion

In the present study, we first demonstrated that SGA sensitivity in patients with liver disease was less than that in patients with gastroenterological disease, even though both SGA specificity and efficiency were similar between the two groups. These results indicate that SGA was not sufficient as a nutritional screening tool for patients with liver diseases.

Nutritional status is well known to influence QOL and prognosis in patients with liver disease [1], [2], [3], [4], [5], [6], [7].

Acknowledgments

This study was supported, in part, by a Grant-in-Aid for Young Scientists (B) (No. 19790643 to T.K.) and a Grant-in-Aid for Scientific Research (C) (No. 21590865 to M.S.) from the Ministry of Education, Culture, Sports, Science and Technology of Japan, by Health and Labour Sciences Research Grants for Research on Hepatitis from the Ministry of Health, Labour and Welfare of Japan, and by a Grant for Cancer Research from Fukuoka Cancer Society.

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