Comparison of recommended daily energy intakes in people with cirrhosis, based on current guidelines, and their directly measured energy requirements: an individual patient data analysis

Abstract

Background and aims: weight-based guidelines for the nutritional management of patients with cirrhosis have been formulated by EASL, ESPEN, AASLD and ISHEN. However, the guidance is discordant both in terms of recommended daily energy intakes, which range from 25 to at least 35 kcal/kg, and whether the reference for calculation should be actual, estimate dry or ideal body weight. This study aimed to compare recommended daily energy intakes with daily energy requirements based on direct measurement of resting energy expenditure (REE). Method: REE was measured, using indirect calorimetry, in 900 patients with cirrhosis (mean [ ± 1SD] age 55.7 ± 11.6 yr; 70% men); total daily energy requirements were determined, for individual patients, using 1.3 × REE. Daily energy intakes were calculated based on recommended intakes of 25, 30 and 35 kcal/kg referenced to actual body weight; ideal body weight calculated using the Hamwi, Devine, Robinson and Miller formulae, and, in patients with ascites, the estimated dry weight. The limits of agreement for each permutation of the recommended intakes and weight reference standards were compared with the calculated required intakes. Results: daily intakes of 25 kcal/kg would provide less energy than required and hence underfeeding in the majority of patients, irrespective of the weight standard used or the presence/absence of ascites. In contrast, daily intakes of 35 kcal/kg would provide more energy than required and hence overfeeding in the majority of patients. Daily intakes of 30 kcal/kg are closest to requirements but would still provide from 452 kcal less to 749 kcal more than required, based on actual body weight in patients without ascites, and from 833 kcal less to 767 kcal more than required based on estimated dry body weight in patients with ascites (Table). Conclusion: the current weight-based guideline for determining daily energy intakes in patients with cirrhosis may pose a significant risk of under or overfeeding and need to be urgently reviewed.