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ENERGY REQUIREMENTS MEASURED BY INDIRECT CALORIMETRY DO NOT CORRELATE TO LIVER TRANSPLANT CANDIDATES SEVERITY OF DISEASE MEASURED WITH MELD
LA MacArthur, J Getty, PL Marotta
Liver Unit, Multi-Organ Transplant Program. London Health Sciences Centre. London, Ontario
BACKGROUND: The prevalence of malnutrition is nearly 100% in cirrhotic candidates for liver transplantation (LT). Chronic liver disease has a considerable influence on resting energy expenditure (REE). Hypermetabolism (measured REE >10% predicted REE) is associated with malnutrition and is found in at least a third of stable cirrhotic patients. No clinical or biochemical markers of liver disease have been identified that would help predict this phenomenon. MELD score measures severity of liver disease independent of nutrition status. It is unknown if MELD score correlates with energy requirements or severity of malnutrition in cirrhotic patients.
OBJECTIVE: Evaluation of the relationship between a calculated MELD score and measured REE (mREE).
METHODS: 14 adult patients with chronic liver disease that were wait listed for LT and agreed to participate in serial nutritional assessments were included. mREE was obtained using indirect calorimetry (IC). Patients included were at high risk of malnutrition due to inability to meet estimated nutritional needs.
RESULTS: All 14 patients had MELD scores used at the time of mREE. Dry body weight was used when weight was <= 125% ideal body weight otherwise adjusted body weight was used. The mean REE/kg dry weight was 27 kcal/kg (range; 19-36). The mean MELD score was 26 (range; 11-40). 71% of patients were hypermetabolic; mREE of 29 kcal/kg (range; 23-36) and the mean MELD was 24 (range; 11-40). 29% of patients were normometabolic (mREE = predicted REE). No patients were hypometabolic (mREE<10% predicted REE). Average age was 54 (range; 45-65). Average BMI was 24 (range; 15.6-43). There was no correlation between MELD and mREE in all patients or in the 10 with hypermetabolic findings.
CONCLUSIONS: Severity of liver disease as measured by MELD does not correlate to energy expenditure in this high-risk group. This study supports the suggestion that REE may vary more with extrahepatic consequences of liver cirrhosis that are not accounted for in the MELD score. Harris Benedict Equation frequently underestimates energy requirements of advanced cirrhotic patients putting hypermetabolic patients at higher risk of nutrition related complications. Measured REE by IC is a valuable tool in severe cirrhotics. Development of an illness severity scale that captures hypermetabolism would be useful in predicting the risk of morbidity and potential mortality from malnutrition in advanced cirrhotics.