The efficacy of parenteral nutrition (PN) and enteral nutrition (EN) supports in cirrhosis: A systematic review and network meta-analysis

IMPORTANCE: Multiple nutritional therapies are currently available for patients with liver cirrhosis, yet many interventions have not been compared head-to-head within randomized clinical trials. OBJECTIVE: To evaluate the improvement of nutritional indicators and liver function indexes of liver cirrhosis treated with different nutrition intervention. DATA SOURCE: We searched PubMed, Embase. com and Cochrane Library database from construction to April 3, 2020. After eliminating the duplicated or overlapping reports, 6 studies were included. We performed a Bayesian network meta-analysis by Stata 12.0 and GeMTC 0.14.3 in order to compare different nutritional interventions with consistency model. STUDY SELECTION: Randomized clinical trials comparing 2 or more therapies in patients with cirrhosis were evaluated. Six randomized clinical trials met the selection criteria. DATA EXTRACTION AND SYNTHESIS: Two investigators independently reviewed the full manuscripts of eligible studies and extracted information into an electronic database: patients’ characteristics study design, interventions, the number of events of interest in each group. MAIN OUTCOMES AND MEASURES: Body mass index, Child-Pugh score, model for end-stage liver disease score, total bilirubin, alanine transaminase, aspartate transaminase, total protein, Triceps skinfold, Midarm Muscle Circumference, Fischer ratio, overall survival. RESULTS: There are 6 studies enrolling a total of 1148 patients who received different nutrition supports including parenteral nutrition (PN), enteral nutrition (EN), EN (without branched-chain amino acids), EN + intestinal probiotics, PN + EN, late evening snacks (LES), EN + LES, noLES. The direct comparisons showed that the effect of EN was better than EN (without branched-chain amino acids); EN + intestinal probiotics was better than EN and PN; PN + EN was better than them alone; EN + LES was better than LES and EN; LES was better than noLES. Although the difference of indirect comparisons between the included regimens was not statistically significant, the results showed that EN + intestinal probiotics appeared to be superior to PN + EN. While LES and EN + LES seemed to rank behind them and the difference between them was extremely small. CONCLUSION AND RELEVANCE: Available evidence suggests that EN + intestinal probiotics appear to be the most effective strategy for patients with cirrhosis compared with other interventions.