Nutritional and functional rehabilitation in cirrhotic patients

Natália Perin Schmidt, Sabrina Alves Fernandes, Andresa Thomé Silveira, Roberta Goulart Rayn, Ana Cristhina Henz, Danusa Rossi, Lucas Homercher Galant, Cláudio Augusto Marroni


Introduction: Cirrhotic people often have impaired nutritional and functional status. Objective: To evaluate the effect of multidisciplinary rehabilitation on cirrhotic patients. Method: Controlled clinical trial conducted at the Gastroenterology Ambulatory in southern Brazil, involving 33 patients with liver cirrhosis, through a multidisciplinary rehabilitation program, distributed into the groups: nutritional intervention (n=22) and functional and nutritional rehabilitation (n=11). Nutritional orientation according to European Society for Clinical Nutrition and Metabolism (ESPEN) Guideline. Functional intervention, during a period of 3 months, three weekly sessions of up to fifty minutes of exercise. Clinical and etiological characteristics, Child Pugh, nutritional, anthropometric and functional aspects were collected. Significant associations values were considered when p<0,05.Results: Mostly male patients (60,6%), average age 58 years (± 11,9 years), prevalence of cryptogenic etiology, Child-Pugh A, well-nourished subjective global assessment (SGA). Significant changes in the parameters abdominal circumference (ABC) (p<0,049), muscular arm circumference (MAC) (p <0,001),six-minute walk test (6mWT) (p<0,001) between the groups, with significant improvement in multidisciplinary rehabilitation. Significant improvement in the indirect parameters of sarcopenia, handshake strength (HS) (p<0,008) and 6mWT (p<0,001), especially in the group with functional and nutritional rehabilitation. Body composition revealed a significant change in multidisciplinary rehabilitation, in Weight (p<0,001), BMI (p<0,001), Phase Angle (PA) (p<0,036), ABC (p<0,002), MAC (p<0,001) and thumb adductor muscle (TAM) (p<0,030), which was not observed in the nutritional intervention group.Conclusion: The multidisciplinary intervention shows positive results, as observed, where the group with the functional and nutritional rehabilitation activity was superior to the group with the isolated nutritional intervention.


Liver cirrhosis; Rehabilitation; Nutritional assessment; Sarcopenia



Ciocîrlan M, Cazan AR, Barbu M, Mănuc M, Diculescu M, Ciocîrlan M. Subjective Global Assessment and Handgrip Strength as Predictive Factors in Patients with Liver Cirrhosis. Gastroenterol Res Pract. 2017; 8348-390. DOI: 10.1155/2017/8348390.

Tandon P, Raman M, Mourtzakis M, Merli M. A practical approach to nutritional screening and assessment in cirrhosis. Hepatology 2017; 65(3) : 1044-57.

Oliveira KS, Reis L, Barther N, Dorneles GP, Peres A, Fernandes SA, et al. Oxidative and antioxidant stress markers in cirrhosis. International Journal of Food Science and Nutrition. 2019; 4(6) : 91-6.

Plauth M, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, et al. ESPEN guideline on clinical nutrition in liver disease. Clin Nutr. 2019; 38(2) : 485-521.

Merli M, Berzigotti A, Zelber-Sagi S, et al. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol. 2019 Jan; (70) : 172-193.

Dasarathy S, Merli M. Sarcopenia do mecanismo ao diagnóstico e tratamento na doença hepática. J Hepatol. 2016; 65(6) : 1232-1244.

Anastacio LR, Ferreira LG, Ribeiro HS, Diniz KGD, Lima AS, Correia MITD, et al. Sarcopenia, obesidade e obesidade sarcopênica em pacientes submetidos ao transplante hepático: estudo prospectivo de composição corporal. ABCD Arq Bras Cir Dig 2019; 32(2) : e1434. DOI: /10.1590/0102-672020190001e1434.

Nunes FF, Bassani L, Fernandes SA, Deutrich ME, Pivatto BC, Marroni CA. Food consumption of cirrhotic patients, comparison with the nutritional status and disease staging. Arq Gastroenterol. 2016; 53(4) : 250-6.

Huo TI, Wu JC, Lin HC, et al. Evaluation of the increase in model for end-stage liver disease (DeltaMELD) score over time as a prognostic predictor in patients with advanced cirrhosis: risk factor analysis and comparison with initial MELD and Child-Turcotte-Pugh score. J Hepatol. 2005; 42(6) : 826-832.

World Health Organization (WHO). Report of the Expert Committee on Physical Status: the use and interpretation of anthropometry. WHO Technical Report Series nº 854. Geneva: World Health Organization; 1995.

Lipschitz DA. Screening for nutritional status in the elderly. Prim Care. 1994; 21(1) : 55-67.

Blackburn GL, Thornton PA. Nutritional assessment of the hospitalized patient. Med Clin North Am. 1979; 63(5) : 11103-11115.

Frisancho AR. Anthropometric standards for the assessment of growth and nutritional status. Ann Arbor:University of Michigan; 1990.

Heyward VH, Stolarczyk LM. Applied body composition assessment. ChampaignIL: Human Kinetics; 1996.

Barbosa-Silva MC, Barros AJ, Wang J, Heymsfield SB, Pierson RN. Bioelectrical impedance analysis: population reference values for phase angle bay age and sex. Am J Clin Nutr. 2005; 82 : 49-52

Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr.1987; 11(1) : 8-13.

González MC, Duarte RRP, Budziareck MB. Adductor pollicis muscle: reference values of its thickness in a healthy population. Clin Nutr 2010; 29 : 268-71.

Fess EE. Grip Strength. 2. ed. Chicago: American Society of Hand Therapists; 1992.

Álvares-da-Silva MR, Silveira TR. O estudo da força do aperto de mão não-dominante em indivíduos sadios: determinação dos valores de referência para o uso da dinamometria. GED Gastroenterol Endosc Dig. 1998; 17 : 203-206.

Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010; 39(4) : 412-23.

Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019; 48(1) : 16-31.

Brooks D, Solway S, Gibbons WJ. ATS Statement on six minute walk test. Am J Resp Crit Care Med 2003; 167 : 1287.

Piña IL, Apstein CS, Balady GJ, et al. Exercise and heart failure: A statement from the American Heart Association Committee on exercise, rehabilitation, and prevention. Circulation. 2003; 107 : 1210-1225.

Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006; 173 : 1390-1413.

Román E, Torrades MT, Nadal MJ, et al. Randomized pilot study: effects of an exercise programme and leucine supplementation in patients with cirrhosis. Dig Dis Sci. 2014; 59 : 1966-1975.

Román E, García-Galcerán C, Torrades T, et al. Effects of an Exercise Programme on Functional Capacity, Body Composition and Risk of Falls in Patients with Cirrhosis: A Randomized Clinical Trial. PLoS One. 2016; 11(3) : e0151652. DOI: 10.1371/journal.pone.0151652.

Belarmino G, Singer P, Gonzalez MC, Machado NM, Cardinelli CS, Barcelos S, et al. Prognostic value of energy expenditure and respiratory quotient measuring in patients with liver cirrhosis. Clin Nutr. 2019 Aug; 38(4) : 1899-1904.

Santos E, Rodríguez A, Prieto C, et al. Moduladores de la ingesta y el gasto calórico e num grupo de pacientes pre-transplante hepático. An Sist Sanit Navar. 2016; 39(1) : 105-114.

Bakshi N, Singh K. Nutrition assessment and its effect on various clinical variables among patients undergoing liver transplant. Hepatobiliary Surg Nutr. 2016; 5(4) : 358-371.

Costa JKL, Assis, SLM, Brilhante V, Guimarães APR. Perfil epidemiológico dos pacientes portadores de cirrose hepática atendidos no Ambulatório de Hepatologia do Centro de Especialidades Médicas do CESUPA (CEMEC), em Belém – PA. GED gastroenterol endosc dig. 2016; 35(1) : 1-8.

Aydos MED, Fernandes SA, Nunes FF, et al. One-year follow-up of the nutritional status of patients undergoing liver transplantation. Nutr Hosp. 2016 Jan; 33(1) : 8-13.

Moreno-Sanchez D. Epidemiology and natural history of primary non-alcoholic fatty liver disease. Gastroenterol Hepatol. 2006; 29(4) : 244-254.

Kojima H, Sakurai S, Matsumura M, et al. Cryptogenic cirrhosis in the region where obesity is not prevalent. World J Gastroenterol. 2006; 12 : 2080-2085.

Sumeet KA, Harshad D, John E, Patrick SK. Burden of liver diseases in the world. Journal of Hepatology. 2019; 70 : 151-171.

Roth GA, Abate D, Abate KH et al. The global, regional, and national burden of cirrhosis by cause in 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2020; 5(3) : 245-266.

Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 agegroups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012; 380 : 2095-2128.

Dondog B, Lise M, Dondov O, Baldandorj B, Franceschi S. Hepatitis B and C virus infections in hepatocellular carcinoma and cirrhosis in Mongolia. Eur J Cancer Prev. 2011; 20 : 33-39.

Meng Q-H, Wang J-H, Yu H-W, et al. Resting energy expenditure and substrate metabolism in Chinese patients with acute or chronic hepatitis B or liver cirrhosis. Intern Med. 2010; 49 (19) : 2085-2091.

Silva DM, Henz AC, Fernandes SA, A. Marroni AC. Nutritional diagnosis of patients with hepatocellular carcinoma: what is the best method? Nutr Hosp. 2019; 36(4) : 884-889.

Fernandes SA, Bassani L, Nunes FF, Aydos ME, Alves AV, Marroni CA. Nutritional assessment in patients with cirrhosis. Arq Gastroenterol. 2012; 49(1) : 19-27.

Vieira PM, De-Souza DA, Oliveira LC. Nutritional assessment in hepatic cirrhosis; clinical, anthropometric, biochemical and hematological parameters. Nutr Hosp. 2013; 28(5) : 1615-1621.

Nunes FF, Fernandes SA, Bertolini CM, Rabito EI, Gottschall CBA. Avaliação nutricional do paciente cirrótico: comparação entre diversos métodos. Sci Med. 2012; 22(1) : 12-7.

Nishida Y, Ide Y, Okada M, et al. Effects of home-based exercise and branched-chain amino acid supplementation on aerobic capacity and glycemic control in patients with cirrhosis. Hepatol Res. 2017; 47(3) : 193-200.

Chen HW, Ferrando A, White MG, et al. Home-Based Physical Activity and Diet Intervention to Improve Physical Function in Advanced Liver Disease: A Randomized Pilot Trial. Dig Dis Sci. 2020. DOI: 10.1007/s10620-019-06034-2.

Mundstock E. Associação do Nível de Atividade Física e do Tempo Sentado com o Ângulo de Fase da Bioimpedância. Tese [Doutorado]. Porto Alegre: Pontifícia Universidade Católica do Rio Grande do Sul; 2018.

Belarmino G, Gonzalez MC, Torrinhas RS, et al. Phase angle obtained by bioelectrical impedance analysis independently predicts mortality in patients with cirrhosis. World J Hepatol. 2017; 9(7) : 401-408.

Barbosa DMO, Daltro CS, Torres AC, et al. Aplicação clínica do ângulo de fase em oncologia. Rev Bras Nutr Clín. 2008; 23(3) : 209-242.

Selberg O, Selberg D. Norms and correlates of bioimpedance phase angle in healthy human subjects, hospitalized patients, and patients with liver cirrhosis. Eur J Appl Physiol. 2002; 86(6) : 509-516.

Marroni CA, Miranda D, Boemeke L, Fernandes SA. Phase Angle Bioelectrical Impedance Analysis (BIA) as a Biomarker Tool for Liver Disease. In: Patel V, Preedy V (eds.). Biomarkers in Liver Disease. Biomarkers in Disease: Methods, Discoveries and Applications. Dordrecht: Springer; 2017 : 735-751.

Aby ES, Saab S. Frailty, Sarcopenia, and Malnutrition in Cirrhotic Patients. Clin Liver Dis. 2019; 23(4) : 589-605.

Pagotto V, Santos KF, Malaquias SG, Márcia B, Silveira EA. Circunferência da panturrilha: validação clínica para avaliação de massa muscular em idosos. Rev Bras Enf. 2018; 71(2) : 322-328.

Rodrigues DO, Ueno E, Theis G, Ramos SAA, Azevedo LC. Nutritional status of patients undergoing liver transplantation. BRASPEN J. 2019; 34(1) : 70-76.

Debette-Gratien M, Tabouret T, Antonini MT, et al. Personalized adapted physical activity before liver transplantation: acceptability and results. Transplantation. 2015; 99 : 145-150.

Aamann L, Dam G, Rinnov AR, Vilstrup H, Gluud LL. Physical exercise for people with cirrhosis. Cochrane Database Syst Rev. 2018 Dec 21; 12(12) : CD012678. DOI: 10.1002/14651858.CD012678.pub2.

Andrade P, Lameu EB. Espessura do músculo adutor do polegar: um novo indicador prognóstico em pacientes clínicos. Ver Bras Nutr Clin. 2007; 22 : 28-35.

Budziareck MB, Pureza D, Rodrigo R, et al. Reference values and determinants for handgrip strength in healthy subjects. Clin Nutr. 2008; 27 : 357-362.

Carey EJ, Steidley DE, Aqel BA, et al. Six-minute walk distance predicts mortality in liver transplant candidates. Liver Transpl. 2010; 16(12) : 1373-1378.

Buchard B, Boirie Y, Cassagnes L, Lamblin G, Coilly A, Abergel A. Assessment of Malnutrition, Sarcopenia and Frailty in Patients with Cirrhosis: Which Tools Should We Use in Clinical Practice? Nutrients. 2020; 12(1) : 186. DOI: 10.3390/nu12010186.

Brustia R, Savier, E, Scatton, O. Physical exercise in cirrhotic patients: Towards prehabilitation on waiting list for liver transplantation. A systematic review and meta-analysis. Clin Res Hepatol Gastroenterol. 2018; 42(3) : 205-215.

Henz AC. Avaliação do gasto energético de repouso em pacientes cirróticos com e sem carcinoma hepatocelular. Dissertação [Mestrado]. Porto Alegre: Universidade Federal de Ciências da Saúde de Porto Alegre; 2019.

Holanda LB, Barros AA. Métodos aplicados em inquéritos alimentares. Rev Paul Pediatria 2006; 24(1) : 62-70.

Full Text: PDF HTML


  • There are currently no refbacks.

Creative Commons License
This work is licensed under a Creative Commons Attribution 3.0 License.