Risk Factors for Malnutrition in Chronic Liver Disease Patients Using RFH-NPT: A Study at Hospital Selayang, Malaysia
DOI:
https://doi.org/10.55489/njcm.161120255649Keywords:
Malnutrition, Chronic Liver Disease, RFH-NPT, Nutritional Status, Health-Related Quality of LifeAbstract
Introduction: Malnutrition is highly prevalent among patients with chronic liver disease (CLD), affecting approximately 50-90% of cases. The Royal Free Hospital Nutritional Prioritizing Tool (RFH-NPT) is a validated screening tool for assessing malnutrition risk in CLD patients, yet its use remains limited in clinical and research settings. This study aimed to identify determinants of malnutrition risk in CLD patients at Hospital Selayang.
Methods: A cross-sectional study was conducted among 85 hospitalized CLD patients from March until June 2024. Anthropometric data, including weight, height, BMI, mid-upper arm circumference, and skinfold thicknesses, were collected. Biochemical parameters were retrieved from medical records. Malnutrition risk was assessed using the validated Malay-translated RFH-NPT, while dietary intake and health-related quality of life (HRQoL) were evaluated using 24-hour recall and the SF-36 questionnaire, respectively. Data were analysed using SPSS version 29, employing descriptive statistics, Chi-square/Fisher-Exact tests, and ordinal logistic regression.
Results: Significant associations were found between anthropometric data, HRQoL and malnutrition risk. Low calorie intake (OR = 25.34, p = 0.028), presence of ascites (OR = 0.076, p = 0.004), and emotional role limitation (OR = 0.114, p = 0.004) were independent predictors of malnutrition risk, all of which increased the risk.
Conclusion: These findings support the clinical utility of RFH-NPT in identifying malnutrition risk among CLD patients.
References
Sharma A, Nagalli S. Chronic Liver Disease. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2025 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554597/
Mendenhall C, Roselle GA, Gartside P, Moritz T. Relationship of Protein Calorie Malnutrition to Alcoholic Liver Disease: A Reexamination of Data from Two Veterans Administration Cooperative Studies. Alcohol Clin Exp Res. 1995;19(3):635-641. DOI: https://doi.org/10.1111/j.1530-0277.1995.tb01560.x PMid:7573786
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: https://doi.org/10.1016/S0399-8320(06)73491-1 PMid:17075467
Siddiqui ATS, Parkash O, Hashmi SA. Malnutrition and liver disease in a developing country. World J Gastroenterol. 2021;27(30):4985-4998. DOI: https://doi.org/10.3748/wjg.v27.i30.4985 PMid:34497430 PMCid:PMC8384735
Dumont C, Wuestenberghs F, Lanthier N, Piessevaux H, Dahlqvist G. Malnutrition is highly prevalent in hospitalized cirrhotic patients and associates with a poor outcome. Acta Gastroenterol Belg. 2022 Apr 1;85(2):311-319. DOI: https://doi.org/10.51821/85.2.9016 PMid:35709775
Bunchorntavakul C, Reddy KR. Review article: malnutrition/sarcopenia and frailty in patients with cirrhosis. Aliment Pharmacol Ther. 2020;51(1):64-77. DOI: https://doi.org/10.1111/apt.15571 PMid:31701570
He Y, Wang Z, Wu S, Li L, Li J, Zhang Y, et al. Screening and assessment of malnutrition in patients with liver cirrhosis. Frontiers in Nutrition. 2024;11:1398690. DOI: https://doi.org/10.3389/fnut.2024.1398690 PMid:39091687 PMCid:PMC11292113
Traub J, Reiss L, Aliwa B, Stadlbauer V. Malnutrition in patients with liver cirrhosis. Nutrients. 2021;13(2):540. DOI: https://doi.org/10.3390/nu13020540 PMid:33562292 PMCid:PMC7915767
Grønkjær LL, Lauridsen MM. Quality of life and unmet needs in patients with chronic liver disease: A mixed-method systematic review. JHEP Reports. 2021;3(6):100370. DOI: https://doi.org/10.1016/j.jhepr.2021.100370 PMid:34805816 PMCid:PMC8585663
Peng JK, Hepgul N, Higginson IJ, Gao W. Symptom prevalence and quality of life of patients with end-stage liver disease: A systematic review and meta-analysis. Palliat Med. 2019;33(1):24-36. DOI: https://doi.org/10.1177/0269216318807051 PMid:30345878 PMCid:PMC6291907
Pazokian M, Esmaeili M. Quality of Life in Patients With Liver Cirrhosis: A Systematic Review. Hosp Pract Res. 2019 Nov 5;4(4):111-116. DOI: https://doi.org/10.15171/hpr.2019.23
Wu Y, Zhu Y, Feng Y, Wang R, Yao N, Zhang M, et al. Royal Free Hospital-Nutritional Prioritizing Tool improves the prediction of malnutrition risk outcomes in liver cirrhosis patients compared with Nutritional Risk Screening 2002. British Journal of Nutrition. 2020 Dec 28;124(12):1293-1302. DOI: https://doi.org/10.1017/S0007114520002366 PMid:32600494 PMCid:PMC7656665
Espina S, Casas-Deza D, Bernal-Monterde V, Domper-Arnal MJ, García-Mateo S, Lué A. Evaluation and Management of Nutritional Consequences of Chronic Liver Diseases. Nutrients. 2023;15(15):3487. DOI: https://doi.org/10.3390/nu15153487 PMid:37571424 PMCid:PMC10421025
Rajab N, Abdul Hamid SB, Mohd Said AH & Md Isa KA. Validation of Nutrition Screening Tool: Royal Free Hospital Nutritional Prioritizing Tool (RFH-NPT) For Chronic Liver Disease Patients. Malaysian Journal of Medicine and Health Sciences. 2023;19(3):130-137. DOI: https://doi.org/10.47836/mjmhs.19.3.17
Lin BW, Yoshida D, Quinn J, Strehlow M. A better way to estimate adult patients' weights. American Journal of Emergency Medicine. 2009 Nov;27(9):1060-1064. DOI: https://doi.org/10.1016/j.ajem.2008.08.018 PMid:19931751
Shahar S, Pooy NS. Predictive equations for estimation of stature in Malaysian elderly people. Asia Pac J Clin Nutr. 2003;12(1):80-84.
Hu FJ, Liu H, Liu XL, Jia SL, Hou LS, Xia X, Dong BR. Mid-upper arm circumference as an alternative screening instrument to appendicular skeletal muscle mass index for diagnosing sarcopenia. Clin Interv Aging. 2021;16:1095-1104. DOI: https://doi.org/10.2147/CIA.S311081 PMid:34163153 PMCid:PMC8214542
Queensland Government. Using Body Mass Index | NEMO [Internet]. 2024. Brisbane: Nutrition Education Materials Online; 2013. Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0031/147937/hphe-usingbmi.pdf
Banack HR, Kim CD, Cook CE, Wasser A, Kaufman JS, Stovitz SD. BMI-for-age percentile curves for older adults. Obesity (Silver Spring). 2025 Mar 10. DOI: https://doi.org/10.1002/oby.24189. Epub ahead of print. PMID: 40065555.
Womersley J. A comparison of the skinfold method with extent of 'overweight' and various weight-height relationships in the assessment of obesity. Br J Nutr. 1977;38(2):271-284. DOI: https://doi.org/10.1079/BJN19770088 PMid:911746
Martin EB, Stotts MJ. Nutrition Considerations in the Cirrhotic Patient [Internet]. 2020 Nov. Available from: https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2020/11/Nutrition-in-Cirrhosis.pdf [Accessed on 01 October, 2025]
Musa AF, Yasin MSM, Smith J, Yakub Ma. The Malay version of SF-36 health survey instrument: testing data quality, scaling assumptions, reliability and validity in post-coronary artery bypass grafting (CABG) surgery patients at the National Heart Institute (Institut Jantung Negara-IJN), Kuala Lumpur. Health Qual Life Outcomes. 2021;19(1):50. DOI: https://doi.org/10.1186/s12955-020-01658-9 PMid:33563262 PMCid:PMC7874445
Hsu TW, Chang HC, Huang CH, Chou MC, Yu YT, Lin LY. Identifying cut-off scores for interpretation of the Heart Failure Impact Questionnaire. Nurs Open. 2018 Jul 16;5(4):575-582. DOI: https://doi.org/10.1002/nop2.168 PMid:30338103 PMCid:PMC6177553
Haj Ali S, Abu Sneineh A, Hasweh R. Nutritional assessment in patients with liver cirrhosis. World J Hepatol. 2022;14(9):1694-1703. DOI: https://doi.org/10.4254/wjh.v14.i9.1694 PMid:36185724 PMCid:PMC9521456
Ndraha S, Simadibrata M. Child Pugh and Male Gender were Related to Nutritional Status of Liver Cirrhosis Patients in Koja Hospital. The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy. 2009;10(3):110-112. doi:10.24871/1032009110-112
Oettl K, Birner-Gruenberger R, Spindelboeck W, et al. Oxidative albumin damage in chronic liver failure: relation to albumin binding capacity, liver dysfunction and survival. J Hepatol. 2013;59(5):978-983. DOI: https://doi.org/10.1016/j.jhep.2013.06.013 PMid:23811308
Oettl K, Stadlbauer V, Petter F, Greilberger J, Putz-Bankuti C, Hallström S, et al. Oxidative damage of albumin in advanced liver disease. Biochim Biophys Acta Mol Basis Dis. 2008 Jul;1782(7-8):469-473. DOI: https://doi.org/10.1016/j.bbadis.2008.04.002 PMid:18498776
Wang J, Zhang Z, Yan X, Li M, Xia J, Liu Y, et al. Albumin-Bilirubin (ALBI) as an accurate and simple prognostic score for chronic hepatitis B-related liver cirrhosis. Digestive and Liver Disease. 2019 Aug 1;51(8):1172-1178. DOI: https://doi.org/10.1016/j.dld.2019.01.011 PMid:30765220
Aller de la Fuente R. Nutrition and Chronic Liver Disease. Clin Drug Investig. 2022;42(Suppl 1):55-61. DOI: https://doi.org/10.1007/s40261-022-01141-x PMid:35484325 PMCid:PMC9205793
Shergill R, Syed W, Rizvi SA, Singh I. Nutritional support in chronic liver disease and cirrhotics. World J Hepatol. 2018;10(10):685-694. DOI: https://doi.org/10.4254/wjh.v10.i10.685 PMid:30386461 PMCid:PMC6206154
Daftari G, Tehrani AN, Pashayee-khamene F, Karimi S, Ahmadzadeh S, Hekmatdoost A, et al. Dietary protein intake and mortality among survivors of liver cirrhosis: a prospective cohort study. BMC Gastroenterol. 2023;23(1):227. DOI: https://doi.org/10.1186/s12876-023-02832-1 PMid:37400778 PMCid:PMC10316618
Nishikawa H, Kazunori YOH, Enomoto H, Nishimura T, Nishiguchi S, Iijima H. Factors associated with longitudinal QOL change in patients with chronic liver diseases. In Vivo (Brooklyn). 2021 Aug 1;35(4):2451-2456. DOI: https://doi.org/10.21873/invivo.12524 PMid:34182530 PMCid:PMC8286528
Janani K, Jain M, Vargese J, Srinivasan V, Harika K, Michael T, et al. Health-related quality of life in liver cirrhosis patients using SF-36 and CLDQ questionnaires. Clin Exp Hepatol. 2018;4(4):232-239. DOI: https://doi.org/10.5114/ceh.2018.80124 PMid:30603670 PMCid:PMC6311749
Teshome E, Hailu W, Adane A, Belayneh Melese E, Abebaw Angaw D, Tarekegn GE. Clinical and individual factors of quality of life of chronic liver disease patients at University of Gondar comprehensive specialized hospital, Northwest Ethiopia 2022. Medicine (United States). 2023 Nov 10;102(45):E35425. DOI: https://doi.org/10.1097/MD.0000000000035425 PMid:37960830 PMCid:PMC10637558
Abdul Hamid SB, Roslan NA. The nutritional profile and quality of life of cirrhosis patients without encephalopathy at Hospital Selayang. Health scope. 2019;Vol 2:303-404.
Wang X, Feng H, Hui Y, Yu Z, Zhao T, Mao L, et al. Neutrophil-to-lymphocyte ratio is associated with malnutrition risk estimated by the Royal Free Hospital-Nutritional Prioritizing Tool in hospitalized cirrhosis. Journal of Parenteral and Enteral Nutrition. 2022 Jan 1;46(1):123-129. DOI: https://doi.org/10.1002/jpen.2097 PMid:33720443
Zhang P, Wang Q, Zhu M, Li P, Wang Y. Differences in nutritional risk assessment between NRS2002, RFH-NPT and LDUST in cirrhotic patients. Sci Rep. 2023 Dec 1;13(1):3306. DOI: https://doi.org/10.1038/s41598-023-30031-1 PMid:36849719 PMCid:PMC9971362
Janota B, Krupowicz A, Noras K, Janczewska E. Evaluation of the nutritional status of patients with liver cirrhosis. World J Hepatol. 2023;15(7):914-924. DOI: https://doi.org/10.4254/wjh.v15.i7.914 PMid:37547031 PMCid:PMC10401412
Luong R, Kim M, Lee A, Carey S. Assessing nutritional status in a cohort of liver cirrhosis outpatients: A prospective cross-sectional study. Nutr Health. 2020 Mar 1;26(1):19-25. DOI: https://doi.org/10.1177/0260106019888362 PMid:31779515
Carvalho L, Parise ER. Evaluation of nutritional status of nonhospitalized patients with liver cirrhosis. Arq Gastroenterol. 2006;43(4):269-274. DOI: https://doi.org/10.1590/S0004-28032006000400005 PMid:17406753
Georgiou A, Yannakoulia M, Papatheodoridis GV., Deutsch M, Alexopoulou A, Vlachogiannakos J, et al. Assessment of dietary habits and the adequacy of dietary intake of patients with cirrhosis-the KIRRHOS study. Clinical Nutrition. 2021 Jun 1;40(6):3992-3998. DOI: https://doi.org/10.1016/j.clnu.2021.04.044 PMid:34139472
Yao J, Zhou X, Yuan L, Niu LY, Zhang A, Shi H, et al. Prognostic value of the third lumbar skeletal muscle mass index in patients with liver cirrhosis and ascites. Clinical Nutrition. 2020 Jun 1;39(6):1908-1913. DOI: https://doi.org/10.1016/j.clnu.2019.08.006 PMid:31472986
Chiu E, Marr K, Taylor L, Lam L, Stapleton M, Tandon P, et al. Malnutrition Impacts Health-Related Quality of Life in Cirrhosis: A Cross-Sectional Study. Nutrition in Clinical Practice. 2020 Feb 1;35(1):119-125. DOI: https://doi.org/10.1002/ncp.10265 PMid:30806489
Elsebaie EM, Abdel-Fattah AN, Bakr NA, Attalah KM, Aweas AHA. Principles of Nutritional Management in Patients with Liver Dysfunction-A Narrative Review. Livers. 2023;3(2):190-218. DOI: https://doi.org/10.3390/livers3020013
Bischoff SC, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, et al. ESPEN practical guideline: Clinical nutrition in liver disease. Clinical Nutrition. 2020 Dec 1;39(12):3533-3562. DOI: https://doi.org/10.1016/j.clnu.2020.09.001 PMid:33213977
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