Valero P/ Enfermería Investiga, Research, Engagement, Teaching and Management Vol. 9 No. 1 2024 (January - March)

SUBJECTIVE GLOBAL ASSESSMENT AND THE ROYAL FREE HOSPITAL GLOBAL EVALUATION IN CHRONIC LIVER

DISEASE

Paola María Valero Cubillán1https://orcid.org/0009-0002-3266-4074,Mareidys Cecilia Daza1https://orcid.org/0000-0003-1653-6566, Hazel Barboza

Zambrano1http://orcid.org/0000-0002-3519-6168 and Hazel Anderson Vásquez1http://orcid.org/0000-0001-8780-4332.

1Specialty in Clinical Nutrition, Division of Graduate Studies, Faculty of Medicine, University of Zulia, Venezuela.

Received: November 2, 2023

Accepted: December 29, 2023

ABSTRACT

Introduction: Malnutrition in patients with chronic liver disease

is common. Its prognostic value for life is indisputable due to its

impact on morbidity and mortality. However, to date there is no

ideal method for nutritional assessment in this pathology.

Objective: to compare the Subjective Global Assessment (SGA)

and the Royal Free Hospital Global Assessment (RFH-GA) as a

nutritional assessment tool in adults with liver disease. Methods:

Cross-sectional, field and correlational study. The non-

probabilistic random sample was made up of 65 subjects, to

whom both nutritional evaluation methods were applied. For

SGA, the Detski form was used and for the evaluation with the

Royal Free Hospital the Morgan algorithm was used. Results: In

the SGA, 52 subjects presented malnutrition (55.4% reflected

moderate malnutrition and 24.6% severe malnutrition). In the

RFH-GA, it was found that 47 subjects presented malnutrition

(46.2% moderate malnutrition and 26.2% severe malnutrition).

Regarding gender, in the SGA, women predominated in

moderate malnutrition in both methods; and in the RFH-GA, men

predominated in severe malnutrition. The SGA presented a

sensitivity of 97%, specificity of 60%; AUC 0.80; (95% CI 0.66 to

0.97), RFH-GA had a sensitivity of 95%, specificity 84% AUC

0.89 (95% CI 0.79 to 1.00). Conclusions: The SGA and RFH-GA

methods demonstrated a sensitivity greater than 90%. However,

the RFH-GA seems to better classify patients with normal

nutritional status, reflecting a greater specificity in relation to that

observed in the SGA.

Keywords: Nutritional assessment, liver cirrhosis, nutritional

status

Corresponding author: Ph.D. Hazel Anderson Vasquez. Email:hazelanderson2001@gmail.com

Valero P/ Enfermería Investiga, Research, Engagement, Teaching and Management Vol. 9 No. 1 2024 (January - March)

INTRODUCTION

The liver is a vital organ that has various functions in the

metabolic processes of macro- and micronutrients, such as

protein synthesis. It has (1) activity as a detoxifying and immune

organ that detects and eliminates pathogens, a great

regenerative and vascular capacity (2). It should be noted that

when some pathogenic factors affect the liver, certain functions

are altered, producing liver disease, which can be acute or

chronic (1,2).

Chronic liver disease (CLD) is a continuous and progressive

process of liver fibrosis, with architectural distortion of the tissue

and formation of regeneration nodules. As it progresses it leads

to the activation of hepatic stellate cells, which lead to an

excessive tissue repair response, which favors liver fibrosis,

cirrhosis and finally liver cancer (3,4). During the course,

complications such as edema, jaundice, portal hypertension,

malnutrition, esophageal varices, ascites and encephalopathy

may appear (5).

The age group in which CLD predominates is between 40 and 60

years (6), according to Lebroc et al. They found in their study that

between 52 and 67 years was the average age at the diagnosis

of liver cirrhosis (7). On the other hand, among the most frequent

causes that lead to chronic liver failure are liver disease

associated with alcohol consumption (60-70%), followed by non-

alcoholic fatty liver, biliary obstruction and hemochromatosis (5-

10%). (5).

In Central European countries, alcohol and viral hepatitis

contribute equally to the disease burden, with alcohol being the

predominant cause in Western countries. Two-thirds of patients

with liver disease died before the age of 65 years. (8-10). It has

been reported that 844 million people in the world suffer from

cirrhosis, with a mortality rate of approximately 2 million per year.

Of those affected, about 20% have compensated cirrhosis and

between 65% to 95% of those who suffer from this pathology

have protein-calorie malnutrition (11).

In this sense, an important aspect that must be evaluated and

monitored in patients with chronic liver disease is the nutritional

status, since, in the evolution of the disease, protein-calorie

malnutrition is the most observed at any stage of the disease and

it is associated with a high morbidity and mortality (12). Its origin

is multifactorial and three factors that contribute to it can be

identified, such as the limitation or reduction of food intake,

alteration in the digestion and absorption of nutrients, and

interference in nutrient metabolism (13,14).

The pathophysiological factors that lead patients with cirrhosis to

varying degrees of malnutrition are complex and very difficult to

be fully understood. As cirrhosis progresses, malnutrition

becomes more pronounced (15). Hence the importance of

evaluating the nutritional status of these patients, with the aim of

identifying whether malnutrition exists and directing therapeutic

measures to prevent the complications that arise from it (16).

Nutritional evaluation in chronic liver disease should be based on

anthropometric methods, which allow the evaluation of body size

and proportions. Likewise, non-anthropometric methods were

used, such as: the evaluation of body composition with a specific

focus on muscle mass, functional evaluation, dietary evaluation,

as well as applying screening tools that allow identifying

nutritional risk (17,18).

In this order of ideas, within the most used methods for detecting

malnutrition or nutritional risk, one of the most used is the Royal

Free Hospital Global Assessment (RFH-GA), as it is a

reproducible nutritional assessment method that correlates with

other measures of body composition and predicts complications

and post-transplant survival (19,20). Likewise, the Subjective

Global Assessment (SGA) is considered another diagnostic tool

for the nutritional status of these patients. It has a sensitivity of

96-98% and a specificity of 82-83% (21-23).

With this method, Nunes et al. (24) evaluated 130 patients with

chronic liver disease (80 men and 50 women aged between 22

to 89 years) through outpatient consultation. They found a

prevalence of malnutrition of 44%, of which 31% presented

moderate malnutrition and 10% were severely malnourished;

Likewise, Sharma et al. (25), in an unicenter cross-sectional

observational study, 251 cirrhotic patients (199 men and 52

women) with an average age of 51 years were evaluated. They

applied the SGA and reported that 65% of the subjects presented

malnutrition (42% moderate malnutrition and 23% severe

malnutrition).

The Royal Free Hospital Global Assessment (RFH-GA) was

developed specifically for use in patients with liver cirrhosis, it is

a global scheme that incorporates subjective and objective

variables (26). Regarding its application, Gottschall et al. (27)

carried out research where they applied different methods (BMI,

SGA, grip strength (HGS), RFH-GA) to evaluate the nutritional

status of 94 adult patients with the hepatitis C virus. The results

obtained reflected that the prevalence of malnutrition was highest

in the grip strength (HGS) 60.6% followed by RFH-GA 53.2%,

while the methods that identified malnutrition the least were the

VGS 16% and the BMI with 6.4%. These authors concluded that

both grip strength (HGS) and RFH-VG can be good methods to

detect malnutrition in subjects with liver disease.

In accordance with the above, it is necessary to carry out studies

that provide evidence on the most appropriate method for the

nutritional diagnosis of these patients. The present study aimed

to compare the Subjective Global Assessment (SGA) and the

Royal Free Hospital Global Assessment (RFH-GA) as a

nutritional assessment tool in adults with liver disease.

METHODS

This research was of a field, correlational and non-

experimental cross-sectional design. The population was

made up of patients who attended the outpatient Nutrition

consultation of the Gastroenterology Service of the University

Hospital of Maracaibo, Zulia state, Venezuela, during the months

of May to November 2019, from which a non-probabilistic random

sample was selected. made up of 65 patients.

This research was approved by the Academic Committee of the

Clinical Nutrition Specialty of the Division of Graduate Studies of

the Faculty of Medicine of the University of Zulia and by the

Ethics Committee of the University Hospital of Maracaibo.

Research procedures were carried out in accordance with the

Declaration of Helsinki (28). All subjects signed the informed

consent. The Inclusion criteria included: a) both genders, b)

age between 25-65 years and c) with a diagnosis of chronic liver

disease. The Exclusion criteria were a) Patients with a

diagnosis of liver failure or cancer b) patients with any acute

complication of the disease (gastrointestinal bleeding, peritonitis,

infections, encephalopathy).

Valero P/ Enfermería Investiga, Research, Engagement, Teaching and Management Vol. 9 No. 1 2024 (January - March)

Procedures:

To collect data from the selected subjects, the following

evaluations were carried out: clinical, anthropometric and dietary

using the respective forms.

Nutritional assessment

For the SGA, the form of Detski et al. was used. (29) that

classifies nutritional status into three categories based on five

parameters: (weight change, dietary intake relative to usual,

gastrointestinal symptoms, functional capacity and metabolic

stress of the underlying diagnosis) and three physical

examination parameters (loss of subcutaneous fat, loss of

muscle mass, and edema/ascites). The components are then

combined to obtain a rating of (A) well nourished, (B) moderately

malnourished, and (C) severely malnourished.

For the evaluation with the Royal Free Hospital SGA, the Morgan

et al. algorithm was used. (30), which includes an algorithm that

includes: Body Mass Index (BMI) greater and less than 20 kg/m2,

arm muscle circumference (greater and less than the 5th

percentile) and dietary intake (is is classified as adequate,

inadequate and insignificant depending on whether it meets the

requirements or is less or more than 500 kcal/day). After the

respective calculations it was classified into 3 categories:

adequately fed, moderately malnourished (or suspected of being

so) and severely malnourished.

Anthropometric indicators:

Weight: The patient with the minimum of clothing possible was

weighed on the scale balanced at zero. The subject remained

standing motionless in the center of the scale with the body

weight distributed between both feet (31). The estimate of dry

weight in ascites was estimated according to the severity of

ascites formulated by Carvalho et al (32), subtracting 2 kg in

patients with grade 1 ascites, 4 kg with grade 2 and 8 kg with

grade 3. To obtain body weight, a platform scale from the Health

Ometer brand Continental Scale Corporation, Bridgeview,

Illinois, USA, calibrated in kg (0.1 kg), was attached with a

stadiometer calibrated in cm (0.1 cm).

Size: They stood with their heels together forming a 45° angle.

The heels, buttocks, back and occipital region were in contact

with the vertical surface of the stadiometer. The recording was

taken in cm, with a forced inspiration of the subject, and with a

slight traction of the anthropometrist from the lower jaw, keeping

the subject with the head in the Frankfurt Plane (31).

Body Mass Index: The Quetelec equation was applied that

includes (BMI): mass (kg)/height (m2), according to which the

patients were classified BMI according to the Campillo criteria

(33), with the point of cut-off of 22 kg/m² patients without ascites,

adapting it to the WHO classification, in the following cut-off

points: Deficit <22, Normal: 22 – 24.9 Overweight: 25-29.9

Obesity I: 30-34, 9 Obesity II: 35.0 to 39.9 and obesity III: 40 or

more.

Mid-arm circumference: the level of the midpoint between the

acromial and radial points was measured. To take this perimeter,

the length of the arm was measured from the beginning; with the

right forearm bent forward (at a 90° angle) perpendicular to the

body and with the back of the hand facing away from the body.

The length was determined by placing the tape on the superior

vertex of the acromion of the scapula to the olecranon of the ulna

(and head of the radius). The individual remained relaxed,

uncovered (no sweater, shirt, etc.), upright, in profile, arms

resting on his thighs. Next, the subject's arm was extended to

pass the measuring tape horizontally (around the arm), without

pressure, and making contact with the skin. At that moment the

perimeter reading was taken (31). Taking into account the

different cut-off points for its assessment: the corresponding

percentile (34).

Dietary indicators:

Dietary intake: for the dietary evaluation, the 24-hour reminder

was used. It consisted of collecting the most detailed information

possible regarding the foods and drinks consumed (type,

quantity, method of preparation, etc.), for three non-consecutive

days (2 business days and one weekend day). The interview was

conducted by a clinical nutritionist who emphasized the quantities

and types of foods, as well as special preparations (recording

measurements and ingredients used). The size of the portions of

the preparations commonly used by each patient were estimated

with the help of modeled foods and measuring equipment

provided by said professional (35). To calculate the contribution

of energy and nutrients, a computer program was used with data

from the Food Composition Table of Venezuela (36). Individual

consumption of energy were expressed in Kcal/day and

macronutrients in grams of protein/day, grams of fat/day and

grams of carbohydrates/day (37).

Analysis of data

The statistical program Statistical Package for the Social

Sciences (IBM SPSS), version 23 for Windows, was used. These

data were previously entered into a database created in Microsoft

Excel for Windows. To verify the normal distribution of the data,

the Kolmogorov test was applied. -Smirnov. The qualitative

variables were expressed in the form of absolute and relative

frequencies. The mean was used as a measure of central

location, as well as the standard deviation.

To determine the suitability characteristics of the studied

methods, they were grouped by pathology. To compare the

methods, they were regrouped into two bivariate variables ESR

and HRF-GA, grouping at-risk and malnourished patients into a

single group. Differences between means were analyzed using

the t for independent samples or the Mann-Whitney test. In the

statistical analysis, the sensitivity (S), the specificity (Sp), the

positive predictive value (PV +) and the negative predictive value

(PV-), and the positive (RV+) and negative (RV-) likelihood ratio

were calculated. They were compared using the ROC (Receiver

operating characteristic) curve (38). The Cronbach method was

applied for reliability. Values of p<0.05 were considered

statistically significant results.

RESULTS

Table 1 shows the distribution of subjects by age and gender

groups. A total of 65 subjects (36 men and 29 women) were

evaluated. In relation to the distribution of age groups, it was

found that the highest prevalence in both genders corresponded

to the age group between 50-65 years, representing 76.9%, with

a predominance in both men and women, reflecting a significant

response in comparison. with the other two age groups.

Valero P/ Enfermería Investiga, Research, Engagement, Teaching and Management Vol. 9 No. 1 2024 (January - March)

Table 2 shows the anthropometric characteristics of the subjects

according to gender, the average current weight in the group of

men was 77±23 kg and in women it was 61.48±13 kg. Likewise,

the dry weight in men was higher, at 70±34 kg, while in women it

was 54.91±12 kg. The height for the male gender was recorded

as 171±5.8 cm and for the female gender it was 157±8.4 cm.

Regarding BMI, in the male group this corresponded to 25.8 ±

7.1 kg/m2

Valero P/ Enfermería Investiga, Research, Engagement, Teaching and Management Vol. 9 No. 1 2024 (January - March)

Table 3 presents the nutritional status determined by the subjective global assessment and the royal free hospital evaluation according

to gender, while in the female group the BMI was 23.13±4.0 kg/m2; In relation to weight loss in the last 3 months, it was very similar

in both groups, with men reflecting a weight loss of 5.94±5.7 kg while in women it was reflected at 5.68±5. .1kg; Finally, the arm

circumference in the male group was observed at 27.23±6.1 cm and in the female group 25.79±3.59 cm.

Table 3 shows the nutritional status determined by the ESR and

the RFH-GA according to gender. Observing in the SGA a total

of 52 patients (80%) presented malnutrition, of which 55.4%

reflected moderate malnutrition and 24.6% severe malnutrition.

Regarding the male gender, 50% presented moderate

malnutrition and 25% severe malnutrition and 25%; while in

women 62% were observed with moderate malnutrition and

24.1% with severe malnutrition. A predominance was observed

in both groups of the female gender for moderate malnutrition.

Severe malnutrition predominated in men. In the same table 3 it

is recorded that RFH-GA was applied to 65 patients of which 47

or 72.4% presented malnutrition, among them 46.2% had

moderate malnutrition, 26.2% severe malnutrition and 27.6% had

adequate nutritional status. In relation to gender distribution,

36.1% of men had moderate malnutrition, 33.3% had severe

malnutrition and 30.6% reflected good nutritional status.

Meanwhile, in women, 58.6% of moderate malnutrition was

evident, 17.2% of severe malnutrition and 24.2% were included

in the normal nutritional status.

Table 4 indicates the reliability of the SGA and the RFH-VG

according to Cronbach's Alpha. In the SGA, the Cronbach's

Alpha was 0.81, while in the RFH-GA, it corresponded to 0.89.

Graph 1 shows the comparison of the COR curve between the SGA Method and HRF-GA, observing that the HRF-GA method has

greater discriminative power for malnutrition, compared to the SGA method, since it has a sensitivity to detect malnutrition of 95%.

specificity of 84%, PV+ 93%, VP- 88%, RV+ 5.93, RV- 0.16. Area under the curve 0.89, with 95% confidence interval (CI 0.79- 1.00)

p<0.01; while SGA has a sensitivity to detect malnutrition of 97%, specificity of 60%; PV+ 84%; PV- 92%, RV+ 2.42, RV- 0.41; the

area under the curve 0.80; with a 95% confidence interval (0.66 – 0.97) p<0.01-

Valero P/ Enfermería Investiga, Research, Engagement, Teaching and Management Vol. 9 No. 1 2024 (January - March)

DISCUSSION

Malnutrition is a common comorbidity in patients with cirrhosis.

Its prognostic value is indisputable since it greatly influences the

evolution of liver diseases, having a great impact on both

morbidity and mortality before and after liver transplantation.

Therefore, early detection and active management is essential

for the well-being and survival of these patients (26). To date,

there is no nutritional evaluation method that can be considered

an ideal model or Gold Standard to adequately classify the

nutritional status of patients with chronic liver disease (38). That

is why the present research aimed to compare both nutritional

assessment tools in adult patients with liver disease.

Different research groups have evaluated different tools for the

nutritional evaluation of cirrhotic patients; SGA being one of the

most studied and recommended. Both the European Association

for the Study of the Liver (EASL) and the European Society for

Enteral and Parenteral Nutrition (ESPEN) recommend its use in

the nutritional evaluation of liver patients (19,39). Taniguchi et al.

(40) report that SGA is one of the most used nutritional screening

tools in various diseases due to its simplicity and safety.

However, its validity to evaluate nutritional status in liver diseases

has been controversial.

Rosemary et al. (16); point out that the SGA is not an adequate

method to measure the risk of malnutrition due to excess, since

when assessing overweight or obese subjects it includes them

within the well-nourished group. So, although the SGA has not

been developed specifically for the nutritional evaluation of

patients with liver disease, some authors consider it as a reliable,

valid tool with predictive value for patients with cirrhosis (13,

41,42).

In the present study, the prevalence of both moderate and severe

malnutrition, determined by ESR, differs from the figures reported

by Moctezuma et al. (43); who applied the ESR to 315 patients

with CLD (66% men and 34% women) with an average age of 54

years, reflecting 60% of malnourished patients, 49% moderate

malnutrition and 11% with severe malnutrition.

On the other hand, Bunchhorntavakul et al. (44), evaluated 60

patients with CLD by SGA with an average age of 57.45 years

(42 men and 18 women), reporting a total of 91.7% malnourished

patients of which 66.7% subjects presented severe malnutrition

and 25% reflected moderate malnutrition. These results were

higher than those reported in the present investigation;

meanwhile El-Mohsen et al. (45), evaluated 125 subjects (72

men and 53 women) with liver cirrhosis by SGA, average age of

56.8 years, finding results similar to those observed in the

present research: 77.6% malnourished subjects, including 61.6%

with moderate malnutrition and 16% with severe malnutrition.

On the other hand, the results obtained through RFH-GA in the

present study were lower than those found by Naqvi et al. (46);

who applied the RFH-GA to 298 subjects (182 male and 116

female) with chronic liver disease, reporting a total of 85.56% of

malnourished subjects, 54.02% subjects with mild malnutrition

Valero P/ Enfermería Investiga, Research, Engagement, Teaching and Management Vol. 9 No. 1 2024 (January - March)

and 31.54% subjects with severe malnutrition. Landa-Galvan et

al. (47); evaluated the nutritional status of 62 patients (51.6%

men and 48.4% women) through different nutritional evaluation

methods including the RFH-GA, reporting 45.2% subjects with

malnutrition, including 35.5% with malnutrition. moderate and

9.7% with severe malnutrition, figures lower than those reported

in this research work.

Regarding the RFH-GA, it could be observed that it classified

fewer patients with malnutrition in relation to the SGA method.

This could be because this nutritional assessment tool includes

the average arm circumference, which can be a good estimator

to calculate muscle reserves, since it is not affected by water

retention like other areas of the body (30). It could also be

explained by the fact that this assessment allows the

classification of nutritional status based on dietary factors, which

allows us to know specifically whether the daily dietary intake is

adequate, inadequate or insignificant and whether it is

contributing to the deterioration of nutritional status (19).

Regarding the validation of the SGA and RFH-GA methods for

detecting the nutritional status of patients with chronic liver

disease, in the present study it was found that the two tools

demonstrated a sensitivity greater than 90%. However, the RFH-

GA seems to better classify patients with normal nutritional

status, reflecting a greater specificity in relation to that observed

in the SGA. In this sense, Castellanos et al. (48) applied this

method to 116 patients (57 men and 64 women) with an average

age of 59 years, finding a sensitivity of 61.3%, and specificity

72.3%, results that differ from those obtained in the present

research work.

CONCLUSIONS

The SGA and RFH-GA methods demonstrated a sensitivity

greater than 90%. However, the RFH-GA seems to better classify

patients with normal nutritional status, reflecting a greater

specificity in relation to that observed in the SGA.

Finally, having simple and validated screening tools in the

nutritional assessment of liver patients is very useful since it

would allow the early detection of malnutrition and would favor

the application of strategies aimed at avoiding or minimizing the

impact of malnutrition on complications, an increase in morbidity

and mortality, hospital stay and healthcare costs.

INTEREST CONFLICT: None declared by the authors.

REFERENCES

1. Ramos C., Christian O., Santoyo A. Castellanos H., Martínez C., Olarte I., Martínez A. Chronic liver failure and hemostasis. Colombian

Journal of Gastroenterology.2017; 32(4): 349-367. DOI:https://doi.org/10.22516/25007440.178

2. Jia Y, Zhong F, Jiang S, Guo Q, Jin H, Wang F, Li M, Wang L, Chen A, Zhang F, Shao J, Zheng S. Periostin in chronic liver diseases:

Current research and future perspectives. Life Sci. 2019;226:91-97. DOI: https://doi.org/10.1016/j.lfs.2019.04.021

3. Sharma A, Nagalli S. Chronic Liver Disease. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023. Available at:

https://www.ncbi.nlm.nih.gov/books/NBK554597/.

4. Dara L, Ji C, Kaplowitz N. The contribution of endoplasmic reticulum stress to liver diseases. Hepatology. 2011 May;53(5):1752-1763.

DOI: https://doi.org/10.1002/hep.24279.

5. Aceves-Martins M. Nutritional care of patients with liver cirrhosis. Nourish Hosp. 2014; 29(2): 246-258.

DOI:https://dx.doi.org/10.3305/nh.2014.29.2.7024.

6. Velázquez Abente S, Girala Salomón M. Etiology, stage and complications of liver cirrhosis in a reference hospital in Paraguay. Virtual

Rev. Soc. Parag. Med. Int. 2018; 5(2): 53-61. DOI:https://doi.org/10.18004/rvspmi/2312-3893/2018.05(02)53-061

7. Lebroc Perez D, Reina Alfonso BE, Camacho Assef JA, Masip Ramirez M. Clinical characterization of patients with liver cirrhosis at

the “Dr. Antonio Luaces Iraola”.. Mediciego. 2011;17(2):1-8. Available in:https://www.medigraphic.com/pdfs/mediciego/mdc-

2011/mdc112f.pdf

8. World Health Organization. Global health sector strategy against viral hepatitis, 2016-2021. Towards the end of viral hepatitis.

Available in:https://apps.who.int/iris/bitstream/handle/10665/250578/WHO-HIV-2016.06-spa.pdf

9. World Health Organization. Hepatitis C. 2020. Available in:https://www.who.int/es/news-room/fact-sheets/detail/hepatitis-c

10. Pimpin L, Cortez-Pinto H, Negro F, Corbould E, Lazarus JV, Webber L, Sheron N; EASL HEPAHEALTH Steering Committee. Burden

of liver disease in Europe: Epidemiology and analysis of risk factors to identify prevention policies. J Hepatol. 2018;69(3):718-735.

DOI:http://dx.doi.org/10.1016/j.jhep.2018.05.011.

11. Vildózola Gonzales H. Etiology and mechanisms of malnutrition in cirrhotic patients. An. Fac. med. 2020; 81(2): 234-241. DOI:

http://dx.doi.org/10.15381/anales.v81i2.18404.

12. Nishikawa H, Osaki Y. Liver Cirrhosis: Evaluation, Nutritional Status, and Prognosis. Mediators Inflamm. 2015; 2015:872152.

DOI:http://dx.doi.org/10.1155/2015/872152.

13. Hepburn C, von Roenn N. Nutrition in Liver Disease - A Review. Curr Gastroenterol Rep. 2023;25(10):242-249.

DOI:http://dx.doi.org/10.1007/s11894-023-00887-4.

14. Cheung K, Lee SS, Raman M. Prevalence and mechanisms of malnutrition in patients with advanced liver disease, and nutrition

management strategies. Clin Gastroenterol Hepatol. 2012;10(2):117-125. DOI:http://dx.doi.org/10.1016/j.cgh.2011.08.016.

15. Espinosa-Flores AJ, Guzman-Ortiz E, Melendez-Mier G, Ternovoy SK, Bueno-Hernandez N, Roldan-Valadez E. A scoping review of

the methods used in patients with liver cirrhosis to assess body composition and their nutritional findings. Eur J Clin Nutr.

2023;77(9):845-854. DOI:http://dx.doi.org/10.1038/s41430-023-01287-7.

16. Romero Sanquiz G, Anderson Vásquez HE, Lizarzábal de Belloso M. Anthropometric evaluation: A useful instrument in patients with

chronic liver disease. Gen. 2009; 63(3):163-166. Available in:http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0016-

35032009000300005&lng=es.

17. Molfino A, Johnson S, Medici V. The Challenges of Nutritional Assessment in Cirrhosis. Curr Nutr Rep. 2017;6(3):274-280.

DOI:http://dx.doi.org/10.1007/s13668-017-0216-8.

Valero P/ Enfermería Investiga, Research, Engagement, Teaching and Management Vol. 9 No. 1 2024 (January - March)

18. 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:http://dx.doi.org/10.3390/nu12010186.

19. European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu ; European Association for the Study of

the Liver. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol. 2019;70(1):172-193.

DOI:http://dx.doi.org/10.1016/j.jhep.2018.06.024.

20. Plauth M, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, Bischoff SC. ESPEN guideline on clinical nutrition in liver disease.

Clin Nutr. 2019;38(2):485-521. DOI:http://dx.doi.org/10.1016/j.clnu.2018.12.022.

21. Laur C, Davidson B, Keller H. Perceptions on Use of the Subjective Global Assessment Before and After It Became Part of Regular

Practice. Nutr Clin Pract. 2019;34(6):906-915. DOI:http://dx.doi.org/10.1002/ncp.10270.

22. Ravasco P., Anderson H., Mardones F. Methods for assessing nutritional status. Nourish Hosp. 2010; 25(Suppl 3): 57-66. Available

at: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S0212-1611201000090 0009&lng=es

23. Romero Sanquiz G, Anderson Vásquez HE, Altamar D, Espina Taborda A F. Subjective and anthropometric global evaluation for the

nutritional diagnosis of patients with chronic liver disease. Gen. 2009; 63(2): 115-118. Available at:

http://ve.scielo.org/scielo.php?script=sci_arttext&pid=S0016-35032009000200009&lng=es.

24. Nunes G, Santos CA, Barosa R, Fonseca C, Barata AT, Fonseca J. Outcome and nutritional assessment of chronic liver disease

patients using anthropometry and Subjective Global Assessment. Arch Gastroenterol. 2017;54(3):225-231.

DOI:http://dx.doi.org/10.1590/S0004-2803.201700000-28.

25. Sharma P, Gupta C, Kumar A, Arora A, Anikhindi SA, Singla V, Bansal N, Jasrotia S. Nutritional assessment and factors affecting

dietary intake in patients with cirrhosis: A single-center observational study. Nutrition. 2021; 84: 111099.

DOI:http://dx.doi.org/10.1016/j.nut.2020.111099.

26. Tandon P, Raman M, Mourtzakis M, Merli M. A practical approach to nutritional screening and assessment in cirrhosis. Hepatology.

2017;65(3):1044-1057. DOI: http://dx.doi.org/10.1002/hep.29003.

27. Gottschall CB, Pereira TG, Rabito EI, Álvares-Da-Silva MR. Nutritional status and dietary intake in non-cirrhotic adult chronic Hepatitis

C patients. Arch Gastroenterol. 2015;52(3):204-209. DOI:http://dx.doi.org/10.1590/S0004-28032015000300010

28. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human

subjects. JAMA. 2013;310(20):2191-2194. DOI:http://dx.doi.org/10.1001/jama.2013.281053.

29. Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, Jeejeebhoy KN. What is global subjective assessment

of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11(1):8-13. DOI:http://dx.doi.org/ 10.1177/014860718701100108.

30. Morgan MY, Madden AM, Soulsby CT, Morris RW. Derivation and validation of a new global method for assessing nutritional status

in patients with cirrhosis. Hepatology. 2006 ;44(4):823-35. DOI:http://dx.doi.org/10.1002/hep.21358.

31. Lohman TG., Roche AF., Martorell R. Anthropometric standardization reference manual. Champaign, Illinois: Human Kinetic Books.

1988.ISBN 087322 121 4.

32. De Carvalho L, Parise ER, Samuel D. Factors associated with nutritional status in liver transplant patients who survived the first year

after transplantation. J Gastroenterol Hepatol. 2010;25(2):391-396. DOI:http://dx.doi.org/10.1111/j.1440-1746.2009.06033.x.

33. Campillo B, Richardet JP, Bories PN. Validation of body mass index for the diagnosis of malnutrition in patients with liver cirrhosis.

Gastroenterol Clin Biol. 2006; 30 (10): 1137-1143. DOI:http://dx.doi.org/10.1016/s0399-8320(06)73491-1.

34. Frisancho AR. New norms of upper limb fat and muscle areas for assessment of nutritional status. Am J Clin Nutr. 1981;34(11):2540-

2545. DOI:http://dx.doi.org/10.1093/ajcn/34.11.2540.

35. Ferrari M. Estimation of intake by 24-hour recall. DIAETA. 2013; 31 (143):20-25. Available at:

http://www.scielo.org.ar/pdf/diaeta/v31n143/v31n143a04.pdf

36. National Institute of Nutrition (INN). Food composition table for practical use. Rev.1999. publication No. 54. Blue Notebooks Series.

Caracas, Venezuela: 1-75. 2001

37. Plauth M, Cabré E, Riggio O, Assis-Camilo M, Pirlich M, Kondrup J; DGEM (German Society for Nutritional Medicine); Ferenci P,

Holm E, Vom Dahl S, Müller MJ, Nolte W; ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN Guidelines on

Enteral Nutrition: Liver disease. Clin Nutr. 2006;25(2):285-294. DOI:http://dx.doi.org/10.1016/j.clnu.2006.01.018.

38. Bauce G, Moya-Sifontes M. Analysis of the ROC curve in the evaluation of anthropometric indicators. Rev Digit Postgraduate. 2022;

11(1): e333. DOI:http://dx.doi.org/10.37910/RDP.2022.11.1.e333

39. Shafiee F., Karandish M., Mohammad A. Determining the ability of Subjective Global Assessment (SGA) to diagnose risk of

malnutrition in hospitalized patients. Journal of Research in Medical and Dental Sciences.2017;(5) 2: 48-55 available at:

https://www.researchgate.net/publication/318211811_Determining_the_ability_of_Subjective_Global_Assessment_SGA_to_diagnos

is_risk_of_malnutrition_in_hospitalized_patients

40. Taniguchi E, Kawaguchi T, Itou M, Oriishi T, Ibi R, Torii M, Yoshida K, Adachi Y, Otsuka M, Uchida Y, Tanaka S, Takakura M, Sata

M. Subjective global assessment is not sufficient to screen patients with defects hepatic metabolism. Nutrition. 2011;27(3):282-286.

DOI:http://dx.doi.org/10.1016/j.nut.2009.10.016.

41. García-Rodríguez MT, López-Calviño B, Piñón-Villar MDC, Otero-Ferreiro A, Suárez-López F, Gómez-Gutiérrez M, Pértega-Díaz S,

Seoane-Pillado MT, Pita-Fernández S. Concordance among methods of nutritional assessment in patients included on the waiting list

for liver transplantation. J Epidemiol. 2017;27(10):469-475. DOI:http://dx.doi.org/10.1016/j.je.2016.09.011.

42. Ferreira LG, Anastácio LR, Lima AS, Correia MI. Assessment of nutritional status of patients waiting for liver transplantation. Clin

Transplant. 2011;25(2):248-254. DOI:http://dx.doi.org/10.1111/j.1399-0012.2010.01228.x.

43. Moctezuma-Velazquez C, Ebadi M, Bhanji RA, Stirnimann G, Tandon P, Montano-Loza AJ. Limited performance of subjective global

assessment compared to computed tomography-determined sarcopenia in predicting adverse clinical outcomes in patients with

cirrhosis. Clin Nutr. 2019;38(6):2696-2703. DOI:http://dx.doi.org/10.1016/j.clnu.2018.11.024.

44. Bunchorntavakul C, Supanun R, Atsawarungruangkit A. Nutritional Status and its Impact on Clinical Outcomes for Patients Admitted

to Hospital with Cirrhosis. J Med Assoc Thai. 2016;99 Suppl 2: S47-55.

Valero P/ Enfermería Investiga, Research, Engagement, Teaching and Management Vol. 9 No. 1 2024 (January - March)

45. El-Mohsen S., Magdy A. Subjective Global Assessment for Patients with Hepatic Cirrhosis, Egypt.International Journal of Science and

Research (IJSR)7(6):1419-1425. DOI: http://dx.doi.org/10.21275/ART20183477

46. Naqvi IH, Mahmood K, Salekeen S, Akhter ST. Determining the frequency and severity of malnutrition and correlating it with the

severity of liver cirrhosis. Turk J Gastroenterol. 2013;24(5):415-422. DOI:http://dx.doi.org/10.4318/tjg.2013.0637.

47. Landa-Galván HV, Milke-García M.ª P., León-Oviedo C., Gutiérrez-Reyes G., Higuera-de la Tijera F., Pérez-Hernández JL et al.

Evaluation of the nutritional status of patients with alcoholic liver cirrhosis treated at the Liver Clinic of the General Hospital of Mexico.

Nourish Hosp. 2012; 27(6): 2006-2014. DOI:https://dx.doi.org/10.3305/nh.2012.27.6.6070.

48. Castellanos Fernández M., Santana Porbén S., García Jordá E., Rodríguez de Miranda A., Barreto Penié J., López Díaz Y. et al.

Influence of malnutrition on the appearance of complications and mortality in cirrhotic patients. Nourish Hosp. 2008; 23(1): 68-74.

Available in:http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S0212-16112008000100011&lng=es.