Reversing malnutrition and low muscle strength with targeted enteral feeding in patients awaiting liver transplant: A randomized controlled trial.

BACKGROUND AND AIMS: Most patients with decompensated cirrhosis fail to meet their nutrition targets. The impact of nasogastric feeding (NGF) on malnutrition in cirrhosis remains unknown. This study aims to assess the impact of pre-transplant NGF on pre- and post-liver transplant outcomes.

APPROACH AND RESULTS: This single-centre, prospective randomized controlled trial of 55 patients with severe malnutrition and low handgrip strength (HGS) compared standard high-energy high-protein diet to diet plus supplemental nocturnal NGF whilst awaiting transplant. The primary outcome was change in HGS. Median age was 58.5 years (IQR 51.1-64), median MELD 24 (20-28.5), and 32 (58%) were male. Median duration of NGF was 63.0 days (34.5-127), following which time the median between group difference in HGS was 3.6 kg (95% CI: 1.7-5.2, p<0.001); an increase of 20% from baseline. Mid upper-arm circumference, triceps skinfold and immune function all increased significantly with NGF. Muscle and nutritional parameters continued to improve with increasing duration of feeding. NGF significantly increased daily energy intake between groups by 1285 kcal (95% CI: 860-1677) and protein intake by 51 g (95% CI: 32-71) (both p<0.001). All NGF patients met >100% of their measured nutritional requirements. Post-transplant clinical outcomes were similar between groups.

CONCLUSION: Targeted enteral feeding before LT improves HGS, anthropometry and immune function in severely malnourished cirrhotic patients. These findings provide a strong rationale for early consideration of NGF to reverse malnutrition and improve muscle strength. Appropriately powered studies should explore whether NGF can also impact clinically relevant outcomes including pre- and post-transplant mortality.