Impact of Outpatient Intensive Nutrition Therapy on Survival and Frailty in Patients With Acute on Chronic Liver Failure: A Randomized Controlled Trial

Introduction: Improvement in the nutritional status of Acute on Chronic Liver Failure (ACLF) patients may lead to reduction in the disease related morbidity and mortality. This study assessed the impact of dietician supported outpatient intensive nutrition therapy (OINT) on survival and frailty in patients with acute on chronic liver failure. Methods: Seventy adult patients with ACLF by Asia Pacific Association for Study of liver (APASL) definition and frailty assessed by Liver frailty Index (LFI) at baseline were randomized 1:1 to receive standard medical therapy (SMT) plus OINT (intervention) versus SMT (control) alone. The primary outcome was an improvement in survival at 3 months. Secondary outcome measures included improvement in frailty, prognostic scores (Model of End stage Liver Disease, MELD, Model of End stage Liver Disease- Sodium, MELD Na, Asia Pacific APASL Research Consortium, AARC score) and hospitalization. Results: There was a significant improvement in overall survival in the intervention group as compared to controls. After a period of 3 months follow up, the survival in OINT group was much better than the SMT group, 91.4% (Standard error (SE): 4.7%) vs 57.1% (SE: 8.4%), P < 0.001). On cox regression model adjusted for age and co-morbidities, inclusion in the intervention arm, baseline SMI, and AARC score were independent predictors of survival at end of 3-months (P < 0.05 each). The LFI score significantly improved in the OINT as compared to SMT, Δ-0.93 -(0.71-1.13) vs Δ -0.33 -(0.44-0.72) (P < 0.001). On cox regression analysis adjusted for age, CTP, MELD, AARC score, and allocation to treatment group, to assess the predictors of improvement in frailty, enrolment in intervention arm and AARC score were independent predictors, P < 0.001 for improvement in frailty. The disease severity as assessed by MELD, MELD-Na, and AARC showed a significant improvement in the OINT group than the SMT arm (P < 0.05). The patients in OINT group had lesser number of hospitalizations 6 (17%) versus 16 (45.7%) (P = 0.010) over the course of 3 months as compared to SMT group. Conclusion: Outpatient intensive nutrition therapy has a significant impact on improving survival, frailty and disease severity of ACLF patients with a reduction in number of hospitalizations and supports the key role of nutrition in addition to standard medical treatment in ACLF patients.