Nutritional and Functional Rehabilitation in Cirrhotic Patients

Natália Perin Schmidt1, Sabrina Alves Fernandes1, Andresa Thomé Silveira1, Roberta Goulart Rayn1, Ana Cristhina Henz1, Danusa Rossi1, Lucas Homercher Galant1, Cláudio Augusto Marroni1

1 Department of Hepatology, Federal University of Health Sciences of Porto Alegre (UFCSPA).

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Cláudio Augusto Marroni, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Rua Sarmento Leite, 245 - Centro Histórico, 90050-170, Porto Alegre, RS, Brasil.
Email: cmarroni@terra.com.br
Telephone: +55 (51) 3303-8700

Received: January 20, 2021
Revised: January 31, 2021
Accepted: February 2, 2021
Published online: April 21, 2021


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.

Key words: Liver cirrhosis; Rehabilitation; Nutritional assessment; Sarcopenia

© 2021 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Schmidt NP, Fernandes SA, Silveira AT, Rayn RG, Henz AC, Rossi D, Galant LH, Marroni CA. Nutritional and Functional Rehabilitation in Cirrhotic Patients. Journal of Gastroenterology and Hepatology Research 2021; 10(2): 3470-3477 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/3075


Protein caloric malnutrition (PCM) is a clinical sine qua non condition of liver cirrhosis and negatively interferes with the prognosis of these patients[1].

In liver cirrhosis, mainly due to portal hypertension, there are pathophysiological changes related to bacterial translocation, exacerbation of pro-inflammatory cytokines, hyperammonemia, reduced growth factor, enhanced by dietary restriction, anorexia, dysgeusia, reduced protein-caloric intake, reduced metabolism and absorption of nutrients, in addition to neuroendocrine dysregulation[2,3]. The consequences of these factors compromise body homeostasis, with reduced protein synthesis, and gluconeogenesis, from branched-chain amino acids, increases and disrupts skeletal muscle, causing sarcopenia[4].

Protein degradation is measured by increased oxygen consumption, measured by indirect calorimetry, where an increase in resting energy expenditure (REE) is observed in 35% of cirrhotic people compared to the healthy population. It is also possible to determine through Electrical Bioimpedance, through the Basal Metabolic Rate (BMR)[4-6].

The nutritional and functional approach of the cirrhotic patient is fundamental in his broad clinical evaluation, as the nuances that appear are very varied and demand changes in lifestyle, habits, nutrition, activities, which can prevent or delay the natural history of the disease[7,8].


This is a prospective case-control study with 33 patients with liver cirrhosis treated at the Gastroenterology Outpatient Clinic of the Brotherhood of Santa Casa de Misericórdia in Porto Alegre, Rio Grande do Sul, Brazil, from June 2018 to September 2019.


The sample was for convenience, since the variables studied have not yet been described in the literature. Eleven patients were included in the Functional and Nutritional Rehabilitation Group (FNG) and twenty two participated only in the Nutritional Intervention (NI) group.

Inclusion criteria were: adults ≥ 18 years old, both sexes, diagnosed with cirrhosis by clinical evidence, laboratory, imaging and, eventually, liver biopsy. Patients on enteral diet, with some amputation of upper or lower limbs, were excluded.

Socio-demographic data, etiology of cirrhosis and disease staging using the Child-Pugh score[9] were collected from electronic medical records during the first consultation.


Weight was measured with a Filizola® anthropometric scale and height was measured with a stadiometer fixed to the wall, with the patient barefoot and in an upright position. The Body Mass Index (BMI) using the formula BMI = Weight (kg) / [Height (cm)]2 and the classification was made according to the World Health Organization[10] for adults, and the cutoff points indicated by Lipschitz, for the elderly[11].

With the Tricipital Skinfold (TS), measured with a Cescorf plicometer, and with the Arm circumference (AC), the Muscular Arm Circumference (MAC) was calculated using the formula MAC = AC (cm) - 0.314 x TS (mm)[12]. To assess the adequation of TS and MAC, the 50th percentile of the measures proposed by Frisancho was used[13]. The abdominal circumference (ABC) and calf circumference (CC) were measured according to Lee et al[14].

Electric Bioimpedance (EBI)

The utilized device was the Biodynamics®, model 450. The patients were instructed about the preparation protocol for the exam. Electrodes were placed at the ends of the body (hand and wrist; foot and ankle), the data of Phase Angle (PA), Lean Mass (LM), Fat Mass (FM) and Basal Metabolic Rate (BMR) were collected and classified based on reference parameters of Barbosa-Silva et al study[15].

Subjective Global Assessment (SGA)

Applied according to a document validated by Detsky et al[16].

Thumb Adductor Muscle (TAM)

A Cescorf® scientific adipometer was used, exerting continuous pressure to pinch the adductor muscle at the apex of an imaginary triangle, formed by the extension of the thumb and index finger. The procedure was done on the dominant hand three times. The result used was the average of the measurements, and the cutoff points, according to sex, proposed by González et al[17].

Handshake Strength (FS)

It was used the Baseline® branded mechanical dynamometer with adjustable handle, Smedley Spring model, manufactured in the state of New York, USA. Three evaluations were performed, with an interval of at least 30 seconds between them, with the highest value being recorded[18]. The cutoff points used, according to sex, were those ued in Álvares da Silva et al[19] study.

24-hour recall (24HR)

The 24HR questionnaire was applied on the day of the outpatient consultation, being asked what, how much and the time of the food consumed by the patient on the previous day. Afterwards, the total amount of calories consumed was calculated using the software - DietBox®.

6-minute walk test (6mWT)

The 6mWT was performed in a straight, flat corridor, 30 meters long, and without any type of obstacle. Before starting the test, all patients were instructed by the examiner and received a standardized verbal stimulus every minute of walking so that they could go through as far as possible. At the end of the test, the distance covered was measured, following the protocol by Brooks et al[20,21]. All evaluations were performed by trained professionals, nutritionists and physical therapists on the team[22].

Nutritional Intervention

The Nutritional Intervention consisted of nutritional guidelines, over a 12-week period, in order to identify the needs for macronutrients and micronutrients, as well as the risks of malnutrition. Thus, the eating plan was calculated using the basal metabolism rate (BMR) derived from EB, respecting the Guideline of the European Society for Clinical Nutrition and Metabolism (ESPEN). The orientation was for energy intake of 25 to 35 kcal/kg of dry body weight/day to maintain body composition, and protein intake between 1.2 to 1.5 g/kg/CW/day, in order to avoid loss of muscle mass and decrease the risk of malnutrition[4].

Functional Intervention

The patients were referred to the physiotherapy laboratory of the Federal University of Health Sciences of Porto Alegre (UFCSPA) in order to perform three weekly exercise sessions for three months. The exercise program for cirrhotic patients was similar to that used for chronic cardiac and pulmonary patients, with a recommendation of aerobic physical activity of moderate intensity for a minimum of 30 minutes, five days a week or vigorous intensity for a minimum of 20 minutes, three days a week, to promote and maintain health[23-26]. The first session consisted of 5 minutes of warm-up, followed by 30 minutes of walking on a running machine, with enough speed to reach 60% to 70% of the heart rate obtained in the peak VO2, verified during the spirometry test. Subsequently, 2 minutes of walking time were added to each session performed, reaching up to 50 minutes of exercise, this time maintained until the end of the 8 weeks of rehabilitation.

All patients included in this study agreed and signed the Informed Consent Form (ICF), previously approved by the Research Ethics Committees of the Brotherhood of Santa Casa de Misericórdia of Porto Alegre and the Federal University of Health Sciences of Porto Alegre (UFCSPA), under CAAE number: UFCSPA 3805918 and 3938979 ISCMPA.


Quantitative variables were described by mean and standard deviation, and categorical variables by absolute and relative frequencies.

To compare means between groups, the t-student test was applied. When comparing proportions, Pearson’s chi square or Fisher’s exact tests were used.

For intra and intergroup comparisons, simultaneously, the Generalized Estimation Equations (GEE) model with Bonferroni adjustment was used.

The level of significance adopted was 5% (p < 0.05), and the analyzes were performed using the SPSS program version 21.0.


With a mean age of 58 years (± 11.9 years), 33 cirrhotic patients were evaluated, 20 (60,6%) of whom were male, subdivided into the FNG (n = 11) and NI (n = 22) groups. The clinical, etiological characteristics, associated diseases, Child Pugh score and nutritional aspects are described in Table 1.

In Table 2, data on anthropometry, EBI, baseline functional and nutritional capacity by group demonstrate a significant difference in MAC (%) and the 6mWT test between groups.

The analysis between the groups showed that there was a significant difference in AC. Regarding the MAC and the 6mWT, which already showed a difference before the intervention, they remained the same. There was a significant difference in protein intake.

Regarding intragroup differences, it was found that there were significant changes in several parameters. In the functional and nutritional rehabilitation (FNG) group, there was an improvement in weight, BMI, PA, AC, HS, TAM, 6mWT, 24HR, 24HR Kcal/Kg and protein intake (p < 0.05). In the nutritional intervention (NI) group, there was an improvement in the 6mWT and protein intake (p < 0.05).

Table 1 Clinical characteristics of cirrhotic patients in the two study groups.
Variables Total sample (n=33) FNG (n=11) NI (n=22) p
Age (years) -average ± SD 58.0 ± 11.956.6 ± 9.958.7 ± 12.90.641
Gender - n (%)    1,000
Male20 (60.6)7 (63.6)13 (59.1) 
Female13 (39.4)4 (36.4)9 (40.9) 
Etiology- n (%)   0.392
Hepatitis12 (36.4)3 (27.3)9 (40.9) 
Alcohol3 (9.1)2 (18.2)1 (4.5) 
Autoimmune2 (6.1)0 (0.0)2 (9.1) 
Cryptogenic16 (48.5)6 (54.5)10 (45.5) 
Patologies- n (%)    
DM15 (45.5)5 (45.5)10 (45.5)1,000
Nephropathy4 (12.1)1 (9.1)3 (13.6)1,000
Heart disease20 (60.6)7 (63.6)13 (59.1)1,000
Dyslipidemia10 (30.3)5 (45.5)5 (22.7)0.24
Child-Pugh- n (%)   1,000
A29 (87.9)10 (90.9)19 (86.4) 
B4 (12.1)1 (9.1)3 (13.6) 
SGA- n (%)   0.218
Well Nourished25 (75.8)10 (90.9)15 (68.2) 
Moderately Malnourished8 (24.2)1 (9.1)7 (31.8) 
Ascites - n (%)3 (9.1)1 (9.1)2 (9.1)1,000

Table 2 Anthropometric characteristics, EBI, baseline functional and nutritional capacity of cirrhotic patients in the two groups under study.
Variables Total sample (n=33) FNG (n=11) NI (n=22)p
Average ± SDAverage ± SDAverage ± SD
Weight81.3 ± 18.586.8 ± 20.878.6 ± 17.10.235
Height1.63 ± 0.111.63 ± 0.111.64 ± 0.110.823
BMI30.3 ± 5.432.4 ± 5.129.3 ± 5.40.128
AC99.6 ± 12.6102.7 ± 9.998.0 ± 13.70.327
MAC (%)75.3 ± 22.961.1 ± 6.982.4 ± 24.90.001
CC38.4 ± 5.340.9 ± 4.637.3 ± 5.40.072
PA6.08 ± 0.896.19 ± 0.606.02 ± 1.010.616
LM (%)65.9 ± 7.964.6 ± 7.466.6 ± 8.20.493
FM (%)34.1 ± 7.835.4 ± 7.433.5 ± 8.10.502
BMR1659 ± 4011731 ± 4561623 ± 3770.474
HS38.1 ± 27.242.7 ± 32.135.8 ± 24.90.498
TAM14.6 ± 7.813.1 ± 7.315.4 ± 8.10.442
6mWT384.9 ± 110.7480.9 ± 63.8336.9 ± 97.5<0.001
24HR (Kcal/Kg) 23.9 ± 5.5725.8 ± 5.023.0 ± 5.70.133

Table 3 Assessment of anthropometry. EBI. functional and nutritional capacity of cirrhotic patients. pre and post intervention by group (to be continued).
Variables Total sample (n=33) FNG (n=11) NI (n=22)p
Media ± DP Media ± DP Media ± DP
Pre81.3 ± 18.586.8 ± 20.878.6 ± 17.10.235
Post80.2 ± 18.384.8 ± 20.277.9 ± 17.20.312
Difference (CI 95%)-1.10 (-2.04 a -0.16)-1.96 (-2.96 a -0.96)-0.67 (-1.96 a 0.62)0.119
Pre30.3 ± 5.432.4 ± 5.129.3 ± 5.40.128
Post29.9 ± 5.431.7 ± 5.129.1 ± 5.50.161
Difference (CI 95%)-0.41 (-0.74 a -0.07)-0.72 (-1.07 a -0.38)-0.25 (-0.71 a 0.21)0.106
Pre6.08 ± 0.886.19 ± 0.606.02 ± 1.010.616
Post6.19 ± 1.096.50 ± 0.716.03 ± 1.220.149
Difference (CI 95%)0.11 (-0.20 a 0.42)0.31 (0.02 a 0.60)0.01 (-0.43 a 0.45)0.261
LM (%)    
Pre65.9 ± 7.964.6 ± 7.466.6 ± 8.20.493
Post65.5 ± 6.565.0 ± 6.165.8 ± 6.80.733
Difference (CI 95%)-0.38 (-1.72 a 0.96)0.46 (-1.20 a 2.12)-0.80 (-2.60 a 1.00)0.312
FM (%)    
Pre34.1 ± 7.835.4 ± 7.433.5 ± 8.10.502
Post33.9 ± 6.733.2 ± 6.934.2 ± 6.80.666
Difference (CI 95%)-0.26 (-1.85 a 1.34)-2.28 (-5.06 a 0.50)0.76 (-1.05 a 2.56)0.073
Pre99.6 ± 12.6102.7 ± 9.998.0 ± 13.70.327
Post98.9 ± 12.3100.9 ± 10.097.9 ± 13.40.451
Difference (CI 95%)-0.69 (-1.57 a 0.18)-1.76 (-2.89 a -0.64)-0.16 (-1.29 a 0.97)0.049
MAC (%)    
Pre75.3 ± 22.961.1 ± 6.982.4 ± 24.90.001
Post72.4 ± 16.361.6 ± 9.377.8 ± 16.6<0.001
Difference (CI 95%)-2.88 (-7.59 a 1.83)0.57 (-2.56 a 3.71)-4.61 (-11.4 a 2.16)0.173
Pre38.4 ± 5.340.9 ± 4.637.3 ± 5.40.072
Post38.4 ± 5.640.4 ± 4.837.4 ± 5.70.107
Difference (CI 95%)-0.03 (-0.72 a 0.66)-0.41 (-1.29 a 0.48)0.16 (-0.77 a 1.08)0.39
Pre38.1 ± 27.242.7 ± 32.135.8 ± 24.90.498
Post42.6 ± 30.150.5 ± 37.238.7 ± 25.90.326
Difference (CI 95%)4.52 (-0.44 a 9.47)7.73 (2.04 a 13.4)2.91 (-3.86 a 9.68)0.285
Pre14.6 ± 7.813.1 ± 7.315.4 ± 8.10.442
Post14.4 ± 7.214.3 ± 7.714.5 ± 7.20.939
Difference (CI 95%)-0.23 (-1.72 a 1.27)1.14 (0.11 a 2.16)-0.91 (-3.04 a 1.22)0.09
Pre384.9 ± 110.7480.9 ± 63.8336.9 ± 97.5 <0.001
Post433.6 ± 105.3530.5 ± 70.0385.2 ± 84.7 <0.001
Difference (CI 95%)48.7 (22.4 a 74.9)49.6 (3.71 a 95.6)48.2 (16.2 a 80.3)0.961
Pre1659 ± 4011731 ± 4561623 ± 3770.479
Post1630 ± 4001721 ± 4591584 ± 3690.37
Difference (CI 95%)-29.1 (-70.5 a 12.4)-10.1 (-59.5 a 39.4)-38.5 (-95.2 a 18.1)0.458
Calories (prescript %)102 (95.9 a 108.1)98.9 (80.1 a 117.8)103.6 (100 a 107.2)0.599
Pre1859 ± 2981886 ± 2421845 ± 3270.678
Post1751 ± 3941708 ± 2381772 ± 4570.588
Difference (CI 95%)-108 (-179 a -37.3)-177 (-215 a -139)-73.5 (-175 a 28.1)0.06
24HR Kcal/Kg    
Pre23.9 ± 5.625.8 ± 5.023.0 ± 5.70.133
Post22.6 ± 5.923.6 ± 4.922.1 ± 6.50.433
Difference (CI 95%)-1.3 (-2.1 a -0.5)-2.2 (-3.0 a -1.4)-0.9 (-2.0 a 0.2)0.068
Pre1.07 ± 0.171.04 ± 0.191.09 ± 0.160.433
Post1.38 ± 0.251.45 ± 0.291.35 ± 0.230.276
Difference (CI 95%)0.32 (0.25 a 0.38)0.41 (0.29 a 0.55)0.26 (0.21 a 0.31)0.033
SGA -Moderately Malnourished*    
Pre8 (24.2)1 (9.1)7 (31.8)0.085
Post8 (24.2)1 (9.1)7 (31.8)0.085
Difference (CI 95%)0.0 (0.0 a 0.0)0.0 (0.0 a 0.0)0.0 (0.0 a 0.0)**
* Significance level p <0.05 **calculation was not possible due to lack of variability


The analyzed patients had an average of 58 years of age (± 11.9 years), similar to those found in other brazilian studies[27,28]. The majority of patients are men (60.6%), which is also similar to the prevalence in the Indian study by Bakshi and Singh[29] and in brazilian studies[30,31].

The cryptogenic etiology was the most prevalent, a fact associated with the inclusion of nonalcoholic steatohepatitis (NASH), as in western and industrialized countries[32-34], prevalence that has been increasing significantly worldwide due to nonalcoholic steatohepatitis (NASH)[35]. This data differs from studies in which hepatitis B, C and alcohol intake are the most prevalent etiologies[36,37].

The Child-Pugh A classification was the most prevalent, similar to the outpatient data found by Costa and collaborators[30], Qing-HuaMeng and collaborators[38], and Silva and collaborators[39]. The vast majority of patients had fewer complications, absence of hepatic encephalopathy (HE) and only 9.1% with ascites.

The Subjective Global Assessment (SGA) showed that the majority had good nutritional status. The 2012 study by Fernandes and colleagues, with 129 brazilian patients, adults with liver cirrhosis, showed that SGA underestimated the prevalence and severity of malnutrition in cirrhotic patients[40]. Vieira et al., with 78 adult brazilian patients with liver cirrhosis, advocate its use for diagnosing the nutritional status of cirrhotic patients for allowing a joint analysis of multiple variables of interest[41]. Nunes et al., with 49 adult brazilian patients with chronic liver disease, consider that SGA should be used as a complement to other nutritional assessment techniques, since it does not have the appropriate sensitivity to identify small variations in the nutritional state[40].

The mean BMI pointed to overweight, and showed a decrease in the total sample, in the FNG intragroup (p < 0.05) and not in the NI (p = 0.285), without varying between groups, as well as weight. This result suggests that the combination of dietary and physical behaviors can bring positive results in weight reduction. Román et al., with the 12-week physical activity program, observed muscle mass gain and, therefore, the weight was not changed[25].

Our data differ from those of Nishida and collaborators, whose observed an average BMI of 24.3 kg/m²[42], characterizing eutrophy, and agree with those of Chen and collaborators who found an average BMI of 30kg/m²[43] converging to the prevalence NAFLD, in which 50 to 90% are obese[39].

The PA of the total sample was 6.08º (± 0.88) pre-intervention and 6.19º (± 1.09) post-intervention and it was not different between groups, pre and post-intervention, however, it increased significantly intragroup, in the FNG, pre and post-intervention (p = 0.036), which was not observed in the NI. The difference may be related to physical activity in the first group. Mundstock suggests a positive association of PA with physical activity, by increasing the integrity of the cell membrane and the change in intracellular content, factors that reflect cellular and individual health[44]. PA is dependent on tissue capacitance and is associated with quality, cell size and integrity[45], and has been validated as a prognostic and survival indicator in critically ill patients, used as a measure of disease severity, as a functional assessment tool and as a general health indicator[46]. According to Oliver Selberg and Daniela Selberg, patients with PA below 4.4° had shorter survival (p < 0.01) than those with higher PA (6.6° ± 1.4)[47]. Fernandes and collaborators and Marroni and collaborators pointed out as a new parameter for the classification of the nutritional status of the cirrhotic patients the cut-off point for the PA of 5.44º[40,48].

The assessments of lean mass and fat mass, obtained through EBI, did not show significant differences intra and between groups, pre and post-intervention (p = 0.579 and p = 0.751, respectively). According to a study by Fernandes and collaborators, EBI has low accuracy in individual or group assessments, but it can be effective for a specific population with individuals without body changes, demonstrating that anthropometric measures may be less sensitive for detecting changes in body composition[40].

There was also a reduction in AC between the groups (p = 0.049) and intra FNG (p = 0.002). In studies (Spanish and Japanese), Román and collaborators and Chen and collaborators found a tendency to decrease AC in the group that performed physical activity for 12 weeks and nutritional monitoring with a contribution of 1.2 to 1.5g/kg/day of protein[26,43].

The MAC measurement was different, initially, between the groups (p = 0.001), which represents a difference in the selection, at random, and remains after the intervention, with no difference between groups (p > 0.05). Instead, Aby and Saab demonstrated MAC as a predictor of mortality in cirrhotic patients[49].

Regard to CC, used in recent studies, with the objective of measuring muscle mass, estimating the prevalence of sarcopenia, predicting disability and mortality[50,51], no significant results were found between and within groups.

FAM measures muscle strength and diagnoses the patient’s nutritional status[8]. Nishida and colleagues associated branched-chain amino acid (BCAA) supplementation and intense exercise to a significant increase in muscle strength[43]. Similar findings, with adapted physical activity for 12 weeks with cirrhotic patients, showed a significant increase in muscle strength parameters[52,53].

In this study, FAM was similar between the two groups (p > 0.05). There was a significant increase within the FNG group (p = 0.008), which was not found in the isolated NI (p = 0.399). There is a difference in the general sample, pre and post, with a significant trend (p = 0.074), with the increase in the number of cases. These differences emphasize the importance of physical activity as a factor in improving muscle status.

No significant change in TAM thickness was found between the two groups in this study. However, when observing the intragroup differences, it was found that there was a significant increase in thickness in the FNG (p = 0.030), probably due to the physical activity developed in that branch of the study. It is noteworthy that in the literature, no studies were found relating the measurement of TAM, specifically, with the nutritional diagnosis in cirrhotic patients. Andrade and Lameu conducted a study with 150 patients with chronic clinical diseases, among which 25% were liver disease patients, and demonstrated that the TAM thickness of the dominant hand was an important prognostic indicator, associated with the evolution to infectious and non-infectious complications. infections and length of hospital stay[54]. Budziareck, Duarte and Barboza-Silva, in a study of 300 healthy individuals, found a strong correlation between TAM thickness and FAM, concluding that the combination of these two methods may be useful for the nutritional evaluation[55].

The 6mWT, an indirect parameter of sarcopenia, showed a significant difference (p < 0.001) between the groups, initially, which may represent a difference in random selection, and remained after the intervention (p < 0.001), with significant improvement in performance. When considering the intragroup difference of the general sample (p < 0.001), FNG (p < 0.034) and NI (p < 0.003), it can be seen that everyone had significant improvement in performance, valuing the intervention.

Carey and collaborators demonstrated that each increase of 100m in the 6mWT was associated with increased survival[56]. Buchard and collaborators and Brustia, Savier and Scatton observed that the 6mWT lower than 250m in the liver pre-transplant is considered a risk factor for mortality[57,58].

Similar to the findings of this study, Román and collaborators observed that cirrhotic patients, with physical activity three times a week, for 12 weeks, increased functional capacity and FAM[26]. Even though anthropometric data does not correlate with changes in muscle mass, there is evidence that cirrhotic patients with low functional capacity have lower post-transplant survival rates and longer hospital stays[43].

The offer of an adequate diet plan for patients should be based on BMR values, which can be estimated by various predictive formulas or by EBI. Most formulas are inaccurate in the presence of liver disease[59]. In this study, the mean value (± SD) of BMR, by EBI, was 1659 ± 401 Kcal daily. It was found that there was no significant difference between groups or intragroup (p > 0.05). The percentage of calories consumed per day demonstrates the good acceptance of the guidelines, respecting the prescribed calories with the determined values, (consumption between 80.1% to 117.8% of the prescribed). There was no significant difference between groups or intragroup (p > 0.05).

The calculation of daily caloric intake by the 24HR showed higher values than those calculated by the EBI. Caloric data retrieved from 24HR and 24HR Kcal/Kg demonstrated consistency in the results, with no significance between groups (p > 0.05), which could be different if the number of patients was higher.

The 24HR presented intragroup significance, in the general sample (p < 0.05) and in the FNG (p < 0.001), with an apparent decrease in intake after the intervention, with the mean (± SD) in the total 24HR sample Kcal/Kg of 23,9 ± 5,6 pre-intervention and 22.6 ± 5.9 post-intervention. Considering that BMR in cirrhotic patients varies between 25 to 35 kcal/Kg of dry body weight/day[4], it could be assumed that the patients analyzed in this study would be consuming less than recommended. Holanda and Barros questioned the use of 24HR due to its limitations and disadvantages, because it does not represent the usual intake, does not accurately estimate it, due to the variation of the daily routine, does not evaluate portions accurately, and because it is a method dependent on the interviewed patient memory[60].

The protein intake reported by the patients shows that there was significance between the groups (p < 0.033), at the same time that there was intragroup significance, in the general sample (p < 0.001), in the FNG (p < 0.001) and NI (p < 0.001). The mean (± SD) in the total protein intake sample (g/Kg/CW/day) was 1.07 ± 0.17 pre-intervention and 1.38 ± 0.25 post-intervention.

The orientation of protein intake varied between 1.2 to 1.5 g/kg/CW/day in order to avoid the loss of muscle mass[4]. The increase in consumption is evident in the post-intervention, at all levels, which valorize the process. Nishida and collaborators evaluated that aminoacids increase liver albumin production, improve insulin resistance and quality of life in cirrhotic patients[42] and, when combined with physical exercise, promote improvement in functional condition and quality of life, reduce malnutrition, prevent sarcopenia and loss of muscle mass, and hepatic encephalopathy[6].

There were also significant changes in the parameters AC and 6mWT between groups and intragroup. Other parameters such as Weight, BMI, AF, TAM and FAM showed significant improvement in FNG, which was not observed in NI.

Although EBI did not present statistical significance in the percentage parameter of lean mass, it was possible to identify significant improvement in the indirect parameters of sarcopenia, FAM, MAP and 6mWT, especially in the group where there was a multidisciplinary intervention, with functional and nutritional rehabilitation.


The multidisciplinary rehabilitation program proposed in this study demonstrated that there was significance in the intervention in the functional and nutritional rehabilitation group (FNG) in relation to the nutritional intervention group (NI) in isolation in AC, in MAC, in the 6mWT and in protein intake.

The indirect parameters of sarcopenia were significant in FNG in relation to NI in the 6mWT; as well as there was a significant intragroup improvement in the FAM and 6mWT parameters.

Body composition revealed a significant change in FNG in relation to NI in AC and MAC. There was a significant improvement within the FNG group in weight, BMI, AF, CA and MAP.

The changes observed, in general, demonstrated that the functional and nutritional rehabilitation group, combining physical activity with nutritional guidance, perform better than the isolated nutritional intervention.


Despite being an unprecedented work in the literature, this study is a preliminary presentation of a broader rehabilitation project in progress, and has limitations related to the small sample size.

Functional and nutritional rehabilitation with cirrhosis is difficult, since the inclusion criteria are very selective, there is low adherence to the programs, the number of patients is limited by their lack of availability, there is limited space for physical activities, and the prospective study requires multidisciplinary professionals working together, simultaneously, for a long period of time, in addition to the economic and financial difficulties for the development of the project.

From this point of view, multidisciplinary intervention is essential and shows positive results, and it is believed that by increasing the number of patients in the sample, it is possible to evidence the changes in a more expressive and consistent way, which would encourage new practices for approaching outpatient cirrhotic patients.


1. 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. [PMID: 28804497]; [DOI: 10.1155/2017/8348390]

2. Tandon P, Raman M, Mourtzakis M, Merli M. A practical approach to nutritional screening and assessment in cirrhosis. Hepatology 2017; 65(3): 1044-57. [PMID: 28027577]; [DOI: 10.1002/hep.29003]

3. 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. [DOI: 10.1590/S0004-2803.202000000-71].

4. 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. [PMID: 3071278]; [DOI: 10.1016/j.clnu.2018.12.022]

5. 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. [PMID: 30144956]; [DOI: 10.1016/j.jhep.2018.06.024]

6. Dasarathy S, Merli M. Sarcopenia from mechanism to diagnosis and treatment in liver disease. J Hepatol. 2016; 65(6): 1232-1244. [PMCID: PMC5116259]; [DOI: 10.1016/j.jhep.2016.07.040]

7. 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]

8. 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. [DOI: 10.1590/S0004-28032016000400008]

9. 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. [PMID: 15885353]; [DOI: 10.1016/j.jhep.2005.01.019]

10. 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. Acces date: October, 2020.

11. Lipschitz DA. Screening for nutritional status in the elderly. Prim Care. 1994; 21(1): 55-67. [PMID: 8197257]

12. Blackburn GL, Thornton PA. Nutritional assessment of the hospitalized patient. Med Clin North Am. 1979; 63(5): 11103-11115. [PMID: 116095]; [DOI: 10.1016/S0025-7125(16)31663-7]

13. Frisancho AR. Anthropometric standards for the assessment of growth and nutritional status. Ann Arbor:University of Michigan; 1990. [DOI: 10.1002/ajpa.1330840116]

14. Lee SY, Gallagher D. Assessment methods in human body composition. Curr Opin Clin Nutr Metab Care. 2008; 11(5): 566-572. [PMID: 1868545]; [DOI:10.1097/MCO.0b013e32830b5f23]

15. 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. [PMID: 16002799]; [DOI: 10.1093/ajcn.82.1.49]

16. 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. [PMID: 3820522]; [DOI: 10.1177/014860718701100108]

17. González MC, Duarte RRP, Budziareck MB. Adductor pollicis muscle: reference values of its thickness in a healthy population. Clin Nutr. 2010; 29: 268-71. [DOI: 10.1016/j.clnu.2009.08.012]

18. Bourgeois B, Fan B, Johannsen N, et al. Improved strength prediction combining clinically available measures of skeletal muscle mass and quality. J Cachexia Sarcopenia Muscle. 2019; 10(1): 84-94. [PMID: 30371008]; [DOI:10.1002/jcsm.12353]

19. 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. Rev Bras Nutr Clin 2014; 29 (1): 63-7. Acces date: July, 2020.

20. 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. [PMID: 20392703]; [DOI: 10.1093/ageing/afq034]

21. Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019; 48(1): 16-31. [PMID: 30312372]; [DOI: 10.1093/ageing/afy169]

22. Brooks D, Solway S, Gibbons WJ. ATS Statement on six minute walk test. Am J Resp Crit Care Med 2003; 167: 1287. [PMID: 12714344]; [DOI: 10.1164/ajrccm.167.9.950]

23. 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. [PMID: 12615804]; [DOI: 10.1161/01.cir.0000055013.92097.40]

24. 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. [PMID: 16760357]; [DOI: 10.1164/rccm.200508-1211ST]

25. 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. [DOI: 10.1007/s10620-014-3086-6]

26. 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. [PMID: 27011355]; [DOI: 10.1371/journal.pone.0151652]

27. 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. [PMID: 30007480]; [DOI: 10.1016/j.clnu.2018.07.001]

28. 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. [DOI: 10.4321/S1137-6627/2016000100012]

29. 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. [PMID: 27500148]; [DOI: 10.21037/hbsn.2016.03.09]

30. 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. [ID: lil-784374]

31. 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. [ISSN 0212-1611 CODEN NUHOEQ S.V.R. 318]

32. Moreno-Sanchez D. Epidemiology and natural history of primary non-alcoholic fatty liver disease. Gastroenterol Hepatol. 2006; 29(4): 244-254. [PMID: 16584696]; [DOI: 10.1157/13085972]

33. 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. [PMID: 16610061]; [DOI: 10.3748/wjg.v12.i13.2080]

34. Sumeet KA, Harshad D, John E, Patrick SK. Burden of liver diseases in the world. Journal of Hepatology. 2019; 70: 151-171. [PMID: 30266282]; [DOI: 10.1016/j.jhep.2018.09.014]

35. 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. [PMID: 31981519]; [DOI: 10.1016/S2468-1253(19)30349-8]

36. 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. [PMID: 23245604]; [DOI: 10.1016/S0140-6736(12)61728-0]

37. 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. [PMID: 21166097]; [DOI: 10.1097/cej.0b013e32833f0c8e]

38. 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. [PMID: 20930434]; [DOI: 10.2169/internalmedicine.49.3967]

39. 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. [DOI: 10.20960/nh.02542]

40. 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. [PMID: 22481682]; [DOI: 10.1590/s0004-28032012000100005]

41. 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. [PMID: 24160225]; [DOI: 10.3305/nh.2013.28.5.6563]

42. 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. [PMID: 27219825]; [DOI: 10.1111/hepr.12748]

43. 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. [PMID: 31907774]; [DOI: 10.1007/s10620-019-06034-2]

44. 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. [DOI: 10.1016/j.clnu.2018.08.031]

45. 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. [PMID: 28321276]; [DOI: 10.4254/wjh.v9.i7.401]

46. Gonzalez MC, Barbosa-Silva TG, Bielemann RM, Gallagher D, Heymsfield SB. Phase angle and its determinants in healthy subjects: influence of body composition. Am J Clin Nutr. 2016 Feb; 103(3): 712-6. [PMID: 26843156]; [DOI: 10.3945/ajcn.115.116772]

47. 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. [PMID: 11944099]; [DOI: 10.1007/s00421-001-0570-4]

48. 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

49. Aby ES, Saab S. Frailty, Sarcopenia, and Malnutrition in Cirrhotic Patients. Clin Liver Dis. 2019; 23(4): 589-605. [PMID: 31563213]; [DOI: 10.1016/j.cld.2019.06.001]

50. 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. [DOI: 10.1590/0034-7167-2017-0121]

51. Merli M, Giusto M, Gentili F, Novelli G, Ferretti G, Riggio O, Corradini SG, Siciliano M, Farcomeni A, Attili AF, Berloco P, Rossi M. Nutritional status: its influence on the outcome of patients undergoing liver transplantation. Liver Int. 2010 Feb; 30(2): 208-14. [PMID: 19840246]; [DOI: 10.1111/j.1478-3231.2009.02135.x]

52. Debette-Gratien M, Tabouret T, Antonini MT, et al. Personalized adapted physical activity before liver transplantation: acceptability and results. Transplantation. 2015; 99: 145-150. [PMID: 25531893]; [DOI: 10.1097/TP.0000000000000245]

53. 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. [PMID: 30575956]; [DOI: 10.1002/14651858.CD012678.pub2]

54. Andrade P, Lameu EB. Espessura do músculo adutor do polegar: um novo indicador prognóstico em pacientes clínicos. Ver Bras Nutr Clin. 2007; 22. [DOI: 128-35. 0.1590/S0100-69912009000500003]

55. Budziareck MB, Pureza D, Rodrigo R, et al. Reference values and determinants for handgrip strength in healthy subjects. Clin Nutr. 2008; 27: 357-362. [PMID: 18455840]; [DOI: 10.1016/j.clnu.2008.03.008]

56. 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. [PMID: 21117246]; [DOI: 10.1002/lt.22167]

57. 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. [PMID: 31936597]; [DOI: 10.3390/nu12010186]

58. 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. [PMID: 29162460]; [DOI: 10.1016/j.clinre.2017.09.005]

59. Henz AC, Marroni CA, Silva DM, Teixeira JM, Silveira TT, Ferreira S, Silveira AT, Schmidt NP, Stein JT, Rayn RG, Fernandes SA. Resting energy expenditure in cirrhotic patients with and without hepatocellular carcinoma. World J Gastrointest Pharmacol Ther. Jan 5, 2021; 12(1): 1-12. [PMID: 33564492]; [DOI: 10.4292/wjgpt.v12.i1.1]

60. Holanda LB, Barros AA. Métodos aplicados em inquéritos alimentares. Rev Paul Pediatria 2006; 24(1): 62-70. Acces date: July, 2020. [ISSN: 0103-0582]


  • There are currently no refbacks.

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