Effects of long-term vitamin E supplementation in alcoholic cirrhotics

Antioxidants attenuate nuclear factor-kappa B activation and tumor necrosis factor-alpha production in alcoholic hepatitis patient monocytes and rat Kupffer cells, in vitro

There is increased tumor necrosis factor-alpha (TNF) activity in alcoholic hepatitis (AH).

OBJECTIVES

To examine the effects of antioxidants and glutathione enhancing agents on NF-kappaB activation and TNF production in Kupffer cells and monocytes.

DESIGN AND METHODS

Isolated rat Kupffer cells and peripheral blood monocytes from AH patients were treated in vitro. NF-kappaB activation was assessed by electrophoretic mobility shift assay and TNF was measured in cell culture supernatants.

RESULTS

Monocytes from AH patients had greater TNF production compared to normal volunteers. Pretreatment with antioxidants or gluathione enhancing agents inhibited TNF production and NF-kappaB activation in both monocytes from normal and AH patients as well as in rat Kupffer cells.

CONCLUSIONS

There may be a therapeutic role for antioxidants or glutathione enhancing agents in disease states with increased TNF activity such as AH.

Nutritional support in alcoholic cirrhotic patients improves host defenses

BACKGROUND

Malnutrition is usual in patients with alcoholic liver disease and is associated with a poor outcome. Nutritional support decreases nutrition-associated complications.

AIM

To demonstrate that nutritional support in ambulatory alcoholic cirrhotic patients improves host defenses.

METHODS

Thirty-one male outpatients with alcoholic cirrhosis CHILD-PUGH B or C were included. Twenty-five subjects completed six months consuming daily a nutritional supplement (Ensure, 1000 Kcal and 35 g protein), in addition to their regular diet. At entrance and every three months, a clinical assessment, nutritional evaluation and indirect calorimetry were performed. Liver function tests and LPS-induced monocyte production of cytokines, salivary secretory IgA, lactulose/mannitol ratio and breath hydrogen tests were also measured in these intervals. Delayed cutaneous hypersensitivity and IgG and IgM antibody response to endotoxin were assessed at entrance and at the end of the study.

RESULTS

Patients drank 85% of the provided supplement as an average. REE, total body fat and serum albumin increased, basal breath hydrogen decreased and cellular immunity improved significantly during the follow up period (p< or =0.03). All the other parameters remained unchanged throughout the study. Six patients (16.2%) died during the study, five due to upper gastrointestinal bleeding.

CONCLUSION

Nutritional support in alcoholic cirrhotic patients improves nutritional status and cell mediated immunity.

Nutritional issues in cirrhosis and liver transplantation

In the past year, some relevant papers on the mechanisms of malnutrition in cirrhosis have been published. Studies investigating the metabolic destiny of leucine after protein breakdown, which have contributed to a better understanding of the pathogenesis of muscle wasting and fat depletion in these patients, deserve particular mention. Also, the demonstration that chronically reducing hyperinsulinaemia in cirrhosis is able to improve insulin sensitivity opens novel pathogenic and therapeutic perspectives for such a metabolic derangement in these patients. Other papers dealt with unsaturated lipids, lipoperoxidation and antioxidants in chronic liver disease. However, randomized trials on parenteral or enteral nutrition in cirrhosis and liver transplantation are missing.

Nutritional and metabolic effects of alcoholism: their relationship with alcoholic liver disease

Excessive alcohol ingestion disturbs the metabolism of most nutrients. Although alcohol can lead to severe hypoglycemia, alcoholics are usually glucose intolerant, probably due to a inhibition of glucose-stimulated insulin secretion. Ethanol intake also leads to negative nitrogen balance and an increased protein turnover. Alcohol also alters lipid metabolism, causing a profound inhibition of lipolysis. Looking for an association between alcohol intake, nutrition, and alcoholic liver disease, we have observed a higher prevalence of subclinical histologic liver damage among obese alcoholics. Multivariate analysis in a large group of alcoholics has shown that obesity is an independent predictor of alcoholic liver disease. Other authors have reported that alcoholics with a history of obesity have a two to three times higher risk of having alcoholic liver disease than non-obese alcoholics. The possible explanation for this association is that the microsomal system, which plays an important pathogenic role in alcoholic liver disease, is induced in non-alcoholic obese subjects and alcoholics. Also, peripheral blood monocyte cells of obese alcoholics produce higher levels of interleukin-1, a cytokine that can contribute to liver damage. The ingestion of polyunsaturated fatty acids can also increase the damaging effects of alcohol on the liver, as has been demonstrated in rats subjected to continuous intragastric infusion of alcohol. Observations in human alcoholics have shown that liver damage is associated with a higher ratio of C:18:1/C:18:0 and a lower ratio of C:22:4/C:18:2 in liver lipids, consistent with an induction of delta 9 desaturase and an increased peroxidation of C:22:4.

Is there any use for nontraditional or alternative therapies in patients with chronic liver disease?

There has been a substantial increase in the use of so-called complementary and alternative therapies by patients with liver disease. Although many such modalities are available, herbal therapies are the most popular, and of these remedies, silymarin extracted from the milk thistle is most widely subscribed to as a remedy for liver diseases. Available evidence points to a potential, but unproven, benefit for this as well as other therapies based on free radical scavenger or antioxidant principles in treating patients with liver disease. These therapies deserve further investigation through experimental studies and well-controlled clinical trials. Benefits to patients from these therapies, especially to patients with established cirrhosis, are most likely to be modest and insignificant. Conversely, the hepatotoxic potential of some alternative treatments is well recognized. As practitioners educating and treating patients with liver disease, we are obliged to be informed about popular alternative therapies, understanding of our patients' need to be partners in their care, and open-minded to the possibility that some benefit may come from some therapies currently regarded as alternative. We need to be effective and tolerant in learning about which alternative treatments our patients are taking, so that we can monitor their effects if any and counsel appropriately against those that may cause harm.

Vitamin E status in patients with liver cirrhosis: normal or deficient?

The study aim was to compare the ratio of vitamin E to serum cholesterol with the serum vitamin E level alone as a measure of vitamin E status in patients with different degrees of liver dysfunction. Assessment of serum vitamin E and total serum cholesterol was performed in 85 patients with liver cirrhosis at Child's stage A (n = 26), B (n = 26), and C (n = 33) and 50 patients with noncirrhotic liver disease. As surrogate markers of liver function, 7alpha-hydroxycholesterol and prealbumin concentrations and the plasma prothrombin time were determined. Mean serum vitamin E concentrations in Child A, B, and C patients were 27.4%, 36.9%, and 37.3% lower, respectively, than in healthy controls (P<.01). Twelve of 26 Child A, 14 of 26 Child B, and 14 of 33 Child C patients had vitamin E deficiency with respect to the absolute values, i.e., serum levels less than 13.76 micromol/L (5% percentile of healthy controls). In contrast, only two of 26 Child A, five of 26 Child B, and five of 33 Child C patients (P<.01 for Child A/B and P<.05 for Child C) were vitamin E-deficient according to the serum vitamin E to cholesterol ratio, i.e., less than 2.86 micromol/mmol. Serum vitamin E was correlated significantly with prealbumin, 7alpha-hydroxycholesterol, and the plasma prothrombin time, but the vitamin E to cholesterol ratio was not. Correcting serum vitamin E for total serum cholesterol in patients with liver cirrhosis leads to the phenomenon of reduced serum vitamin E levels inadvertently shifted toward normal values. In patients with liver cirrhosis, the absolute vitamin E concentration correlates better with the typical clinical and biochemical findings of the disease than the vitamin E to cholesterol ratio. Therefore, a considerable number of patients with advanced liver cirrhosis might actually be vitamin E-deficient.

Metabolism of ethanol and some associated adverse effects on the liver and the stomach

Current knowledge of alcohol oxidation and its effects on hepatic metabolism and its toxicity are summarized. This includes an evaluation of the relationship of the level of consumption to its interaction with nutrients (especially retinoids, carotenoids, and folate) and the development of various stages of liver disease. Ethanol metabolism in the stomach and its link to pathology and Helicobacter pylori is reviewed. Promising therapeutic approaches evolving from newly gained insight in the pathogenesis of medical complications of alcoholism are outlined. At present, the established approach for the prevention and treatment of alcoholism are outlined. At present, the established approach for the prevention and treatment of alcoholic liver injury is to control alcohol abuse, with the judicial application of selective antioxidant therapy, instituted at early stages, prior to the social or medical disintegration of the patient, and associated with antiinflammatory agents at the acute phase of alcoholic hepatitis. In addition, effective antifibrotic therapy may soon become available.

Fatty acid composition of liver total lipids in alcoholic patients with and without liver damage

Alcohol ingestion may promote lipid peroxidation, and the presence of polyunsaturated fatty acids in liver lipids may be essential for the generation of liver damage through this mechanism. The aim of this study is to examine fatty acid composition of liver lipids in chronic alcoholics with and without histological liver damage. A percutaneous liver biopsy was performed to 28 patients hospitalized for treatment of their alcoholism. Liver total lipids were extracted from a portion of the tissue sample and fatty acid composition was measured by gas chromatography. Another piece of the sample was sent for histological study. Six patients had histological cirrhosis or alcoholic hepatitis in their biopsies, the rest of the patients had minimal changes. Patients with liver damage had higher levels of oleic acid and total monoenoic fatty acids, a higher 18:1/18:0 ratio, lower levels of polyunsaturated fatty acids, a lower 20:4/18:2 ratio, and a lower peroxidability index in liver total lipids, than patients without liver damage. Alcoholic patients with asymptomatic liver damage have less unsaturated fatty acids in liver total lipids than their counterparts with normal livers.