Resting energy expenditure should be measured in patients with cirrhosis, not predicted

LncRNA taurine upregulated gene 1 in liver disease

Long non-coding RNAs (lncRNAs) are RNA sequences exceeding 200 nucleotides in length that lack protein-coding capacity and participate in diverse biological processes in the human body, particularly exerting a pivotal role in disease surveillance, diagnosis, and progression. Taurine upregulated gene 1 (TUG1) is a versatile lncRNA, and recent studies have revealed that the aberrant expression or function of TUG1 is intricately linked to the pathogenesis of liver diseases. Consequently, we have summarized the current understanding of the mechanism of TUG1 in liver diseases such as liver fibrosis, fatty liver, cirrhosis, liver injury, hepatitis, and liver cancer. Moreover, mounting evidence suggests that interventions targeting TUG1 or its downstream pathways may hold therapeutic promise for liver diseases. This review elucidates the characteristics, mechanisms, and targets of TUG1 in liver diseases, offering a theoretical basis for the prevention, diagnosis, treatment, and prognostic biomarkers of liver diseases.

Predicted estimates of resting energy expenditure have limited clinical utility in patients with cirrhosis

BACKGROUND & AIMS

Malnutrition is associated with adverse clinical outcomes in patients with cirrhosis. Accurate assessment of energy requirements is needed to optimize dietary intake. Resting energy expenditure (REE), the major component of total energy expenditure, can be measured using indirect calorimetry (mREE) or estimated using prediction equations (pREE). This study assessed the usefulness of predicted estimates of REE in this patient population.

METHODS

Individual mREE data were available for 900 patients with cirrhosis (mean [±1 SD] age 55.7±11.6 years-old; 70% men; 52% south-east Asian) and 282 healthy controls (mean age 36.0±12.8 years-old; 52% men; 18% south-east Asian). Metabolic status was classified using thresholds based on the mean ± 1 SD of the mREE in the healthy controls. Comparisons were made between mREE and pREE estimates obtained using the Harris-Benedict, Mifflin, Schofield and Henry equations. Stepwise regression was used to build 3 new prediction models which included sex, ethnicity, body composition measures, and model for end-stage liver disease scores.

RESULTS

The mean mREE was significantly higher in patients than controls when referenced to dry body weight (22.4±3.8 cf. 20.8±2.6 kcal/kg/24 hr; p <0.001); there were no significant sex differences. The mean mREE was significantly higher in Caucasian than Asian patients (23.1±4.4 cf. 21.7±2.9 kcal/kg/24 hr; p <0.001). Overall, 37.1% of Caucasian and 25.3% of Asian patients were classified as hypermetabolic. The differences between mREE and pREE were both statistically and clinically relevant; in the total patient population, pREE estimates ranged from 501 kcal/24 hr less to 548 kcal/24 hr more than the mREE. Newly derived prediction equations provided better estimates of mREE but still had limited clinical utility.

CONCLUSIONS

Prediction equations do not provide useful estimates of REE in patients with cirrhosis. REE should be directly measured.

LAY SUMMARY

People with cirrhosis are often malnourished and this has a detrimental effect on outcome. Provision of an adequate diet is very important and is best achieved by measuring daily energy requirements and adjusting dietary intake accordingly. Prediction equations, which use information on age, sex, weight, and height can be used to estimate energy requirements; however, the results they provide are not accurate enough for clinical use, particularly as they vary according to sex and ethnicity.

[ESPEN Practical Guideline: Clinical nutrition in liver disease]

BACKGROUND

the Practical Guideline is based on the current scientific ESPEN guide on Clinical Nutrition in Liver Disease.

METHODS

it has been shortened and transformed into flow charts for easier use in clinical practice. The guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with chronic liver disease.

RESULTS

a total of 103 statements and recommendations are presented with short commentaries for the nutritional and metabolic management of patients with (i) acute liver failure, (ii) alcoholic steatohepatitis, (iii) non-alcoholic fatty liver disease, (iv) liver cirrhosis, and (v) liver surgery/transplantation. Disease-related recommendations are preceded by general recommendations on the diagnosis of nutritional status in liver patients and on liver complications associated with medical nutrition.

CONCLUSION

this Practical Guideline gives guidance to health care providers involved in the management of liver disease on how to offer optimal nutritional care.

Different combinations of the GLIM criteria for patients awaiting a liver transplant: Poor performance for malnutrition diagnosis but a potentially useful prognostic tool

BACKGROUND & AIMS

Studies using the Global Leadership Initiative on Malnutrition (GLIM) criteria for patients with liver cirrhosis are limited. This study aimed to assess the impact of malnutrition according to the GLIM criteria on the outcomes of patients awaiting a liver transplant (LTx) and compare these criteria with Subjective Global Assessment (SGA).

METHODS

This retrospective observational study included adult patients awaiting LTx. Patient clinical data, nutritional status according to various tools including SGA, and resting energy expenditure were assessed. The distinct phenotypic and etiologic criteria provided 36 different GLIM combinations. The GLIM criteria and SGA were compared using the kappa coefficient. The variables associated with mortality before and after the LTx and with a longer length of stay (LOS) after LTx (≥18 days) were assessed by Cox regression and logistic regression analyses, respectively.

RESULTS

A total of 152 patients were included [median age 52.0 (interquartile range: 46.5-59.5) years; 66.4% men; 63.2% malnourished according to SGA]. The prevalence of malnutrition according to the GLIM criteria ranged from 0.7% to 30.9%. The majority of the GLIM combinations exhibited poor agreement with SGA. Independent predictors of mortality before and after LTx were presence of ascites or edema (p = 0.011; HR:2.58; CI95%:1.24-5.36), GLIM 32 (PA-phase angle + MELD) (p = 0.026; HR:2.08; CI95%:1.09-3.97), GLIM 33 (PA + MELD-Na≥12) (p = 0.018; HR:2.17; CI95%:1.14-4.13), and GLIM 34 (PA + Child-Pugh) (p = 0.043; HR:1.96; CI95%:1.02-3.77). Malnutrition according to GLIM 28 (handgrip strength + Child-Pugh) was independently associated with a longer LOS (p = 0.029; OR:7.21; CI95%:1.22-42.50).

CONCLUSION

The majority of GLIM combinations had poor agreement with SGA, and 4 of the 36 GLIM combinations were independently associated with adverse outcomes.

Nutrition in Chronic Liver Disease: Consensus Statement of the Indian National Association for Study of the Liver

Malnutrition and sarcopenia are common in patients with chronic liver disease and are associated with increased risk of decompensation, infections, wait-list mortality and poorer outcomes after liver transplantation. Assessment of nutritional status and management of malnutrition are therefore essential to improve outcomes in patients with chronic liver disease. This consensus statement of the Indian National Association for Study of the Liver provides a comprehensive review of nutrition in chronic liver disease and gives recommendations for nutritional screening and treatment in specific clinical scenarios of malnutrition in cirrhosis in adults as well as children with chronic liver disease and metabolic disorders.

Malnutrition in cirrhosis: More food for thought

Malnutrition is highly prevalent in liver cirrhosis and its presence carries important prognostic implications. The clinical conditions and pathophysiological mechanisms that cause malnutrition in cirrhosis are multiple and interrelated. Anorexia and liver decompensation symptoms lead to poor dietary intake; metabolic changes characterised by elevated energy expenditure, reduced glycogen storage, an accelerated starvation response and protein catabolism result in muscle and fat wasting; and, malabsorption renders the cirrhotic patient unable to fully absorb or utilise food that has been consumed. Malnutrition is therefore a considerable challenge to manage effectively, particularly as liver disease progresses. A high energy, high protein diet is recognised as standard of care, yet patients struggle to follow this recommendation and there is limited evidence to guide malnutrition interventions in cirrhosis and liver transplantation. In this review, we seek to detail the factors which contribute to poor nutritional status in liver disease, and highlight complexities far greater than "poor appetite" or "reduced oral intake" leading to malnutrition. We also discuss management strategies to optimise nutritional status in this patient group, which target the inter-related mechanisms unique to advanced liver disease. Finally, future research requirements are suggested, to develop effective treatments for one of the most common and debilitating complications afflicting cirrhotic patients.

ESPEN practical guideline: Clinical nutrition in liver disease

BACKGROUND

The Practical guideline is based on the current scientific ESPEN guideline on Clinical Nutrition in Liver Disease.

METHODS

It has been shortened and transformed into flow charts for easier use in clinical practice. The guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with chronic liver disease.

RESULTS

A total of 103 statements and recommendations are presented with short commentaries for the nutritional and metabolic management of patients with (i) acute liver failure, (ii) alcoholic steatohepatitis, (iii) non-alcoholic fatty liver disease, (iv) liver cirrhosis, and (v) liver surgery/transplantation. The disease-related recommendations are preceded by general recommendations on the diagnostics of nutritional status in liver patients and on liver complications associated with medical nutrition.

CONCLUSION

This practical guideline gives guidance to health care providers involved in the management of liver disease to offer optimal nutritional care.

Nutrition in Chronic Liver Disease: A Point-of-Care Review

Patients with chronic liver disease have a very high lifetime risk of malnourishment. It has been increasingly identified in literature that the severity of liver disease affects severity of malnutrition and vice versa. The objective of this review article is to recognize the severity of complications associated with malnutrition in patients with cirrhosis and ways to overcome these obstacles.

Are Predictive Energy Expenditure Equations Accurate in Cirrhosis?

Malnutrition is associated with significant morbidity and mortality in cirrhosis. An accurate nutrition prescription is an essential component of care, often estimated using time-efficient predictive equations. Our aim was to compare resting energy expenditure (REE) estimated using predictive equations (predicted REE, pREE) versus REE measured using gold-standard, indirect calorimetry (IC) (measured REE, mREE). We included full-text English language studies in adults with cirrhosis comparing pREE versus mREE. The mean differences across studies were pooled with RevMan 5.3 software. A total of 17 studies (1883 patients) were analyzed. The pooled cohort was comprised of 65% men with a mean age of 53 ± 7 years. Only 45% of predictive equations estimated energy requirements to within 90⁻110% of mREE using IC. Eighty-three percent of predictive equations underestimated and 28% overestimated energy needs by ±10%. When pooled, the mean difference between the mREE and pREE was lowest for the Harris⁻Benedict equation, with an underestimation of 54 (95% CI: 30⁻137) kcal/d. The pooled analysis was associated with significant heterogeneity (I² = 94%). In conclusion, predictive equations calculating REE have limited accuracy in patients with cirrhosis, most commonly underestimating energy requirements and are associated with wide variations in individual comparative data.

ESPEN guideline on clinical nutrition in liver disease

This update of evidence-based guidelines (GL) aims to translate current evidence and expert opinion into recommendations for multidisciplinary teams responsible for the optimal nutritional and metabolic management of adult patients with liver disease. The GL was commissioned and financially supported by ESPEN. Members of the guideline group were selected by ESPEN. We searched for meta-analyses, systematic reviews and single clinical trials based on clinical questions according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing the SIGN method. A total of 85 recommendations were made for the nutritional and metabolic management of patients with acute liver failure, severe alcoholic steatohepatitis, non-alcoholic fatty liver disease, liver cirrhosis, liver surgery and transplantation as well as nutrition associated liver injury distinct from fatty liver disease. The recommendations are preceded by statements covering current knowledge of the underlying pathophysiology and pathobiochemistry as well as pertinent methods for the assessment of nutritional status and body composition.

EASL Clinical Practice Guidelines on nutrition in chronic liver disease

A frequent complication in liver cirrhosis is malnutrition, which is associated with the progression of liver failure, and with a higher rate of complications including infections, hepatic encephalopathy and ascites. In recent years, the rising prevalence of obesity has led to an increase in the number of cirrhosis cases related to non-alcoholic steatohepatitis. Malnutrition, obesity and sarcopenic obesity may worsen the prognosis of patients with liver cirrhosis and lower their survival. Nutritional monitoring and intervention is therefore crucial in chronic liver disease. These Clinical Practice Guidelines review the present knowledge in the field of nutrition in chronic liver disease and promote further research on this topic. Screening, assessment and principles of nutritional management are examined, with recommendations provided in specific settings such as hepatic encephalopathy, cirrhotic patients with bone disease, patients undergoing liver surgery or transplantation and critically ill cirrhotic patients.

Nutrition in Pediatric Chronic Liver Disease

More than one-half of children with chronic liver disease suffer from malnutrition, which leads not only to a poor quality of life and even possibly catastrophic complications, but also to poor outcomes after a liver transplantation. These children have increased metabolic demands but often decreased intake with malabsorption and altered nutrient utilization, all of which make it difficult to keep up with nutritional demands. Assessment of a patient's nutritional status should be timely, and it should be performed routinely and proactively. When specific nutritional needs are identified, these should be addressed with a multidisciplinary team approach and with the close guidance of an experienced pediatric dietician. The assessment includes anthropometric and laboratory assessments, in addition to a careful physical examination and a detailed patient history. The specific nutritional needs vary, but generally dietary intervention focuses on increasing caloric intake, supplementation with medium-chain triglycerides, and prevention of essential fatty acid and fat-soluble vitamin deficiencies. [Pediatr Ann. 2018;47(11):e445-e451.].

Routine resting energy expenditure measurement increases effectiveness of dietary intervention in obesity

AIMS

Primary outcome of this observational study was to compare weight changes in two groups of overweight and obese individuals: subjects who had a diet prescribed on the base of resting energy expenditure (REE) measured by indirect calorimetry and subjects whose REE was estimated by a predictive equation. In addition, we analyzed differences in weight and metabolic parameter variation in subjects with and without an adequate to predicted REE.

METHODS

We retrospectively analyzed data of 355 overweight and obese patients: 215 on a diet based on REE measured by indirect calorimetry and 140 following a diet based on REE estimated by the Harris-Benedict equation. Anthropometric and metabolic parameters were evaluated for 18 months from baseline. Propensity score adjustment was used to adjust for known differences between the groups being compared.

RESULTS

A significant greater decrease in body weight was observed in the group that underwent indirect calorimetry compared to the group that did not undergo it (p < 0.001). No significant differences were observed between patients with not adequate to predicted REE compared to patients with adequate to predicted REE.

CONCLUSIONS

A weight reduction program based on REE measurement appears more effective than a dietary program based on predictive formulas. This study suggests the routine use of indirect calorimetry in all weight reduction procedures.

Customized nutrition intervention and personalized counseling helps achieve nutrition targets in perioperative liver transplant patients

BACKGROUND AND AIM

Nutritional therapy is an integral part of care in all phases of liver transplantation (LTx). However, there are several factors that make it a challenge to manage malnutrition in these patients including, but not limited to, loss of appetite, dietary restrictions and dietary habits. Dietary habits are guided by personal choice, social, cultural and regional background with diversity ranging from veganism to vegetarianism with the latter predominant in Indian population. Therefore, it is difficult to improve nutritional intake of patients with standard dietary recommendations. We evaluated the effects of implementing personalized dietary counseling and a customized nutrition plan on its ability to enhance oral intake and, thereby improve nutritional status of patients with end stage liver disease (ESLD) being evaluated for LTx. We compared the outcomes with a matched group of patients who were prescribed standard dietary recommendations from a historic database. Primary outcome was measured by number of patients achieving ≥75% of recommended energy and protein requirements during hospitalization for LTx. Secondary outcomes included mean energy and protein intake, hours of ventilation, length of stay in Intensive Care Unit (ICU) and hospital, mortality and readmission rate in the acute phase (3months) after LTx.

METHODS

This was a prospective observational study, performed at a single LTx centre. All patients >18years who enrolled for LTx and consented for the study were included. The study was conducted after obtaining institutional ethics committee approval. A protocol based nutrition planning was implemented from April'14. According to this protocol, all patients being evaluated for LTx underwent a detailed nutritional assessment by a qualified Clinical Dietitian (CD) and regularly followed up with until LTx. Nutritional intervention, including a customized nutrition care plan and personalized dietary counseling, was provided based on the severity of malnutrition. To evaluate the efficacy of this protocol, we compared the nutritional adequacy (calorie and protein intake) of 65 consecutive patients who underwent LTx between August'14-October'15 (group 1) with a historic database of 65 patients who underwent LTx between January'13 and April'14 (group 2). Patients' demographics, disease severity score, baseline markers of nutritional status (subjective global assessment (SGA), and body mass index (BMI)), were recorded. First, assessment of individual patient's oral energy and protein intake was determined by the daily calorie count during hospitalization. Then the nutritional intervention (oral nutrition supplement (ONS)/enteral nutrition (EN)/parenteral nutrition (PN)) plan was customized according to their spontaneous oral intake. As part of the protocol, health related quality of life was also assessed using short form 8 (SF-8) in group 1. Statistical analyses using Pearson's correlation, Chi-Square test were applied with SPSS version 20.0.

RESULTS

The mean age of group 1 and 2 were 52.6 ± 9.8, 51.9 ± 10.5 (range 25-70years) with BMI of 26.8 ± 6.0, 26.5 ± 5.4 respectively. According to SGA, there was significant improvement in the nutritional status of group 1 patients compared to group 2 on admission for LTx. It was indicated that 88% of group 1 individuals in comparison to 98% in group 2 were malnourished. The calorie intake of group 1 (1740.2 ± 254.8) was significantly higher than group 2 (1568.5 ± 321.6) (p = 0.005). The marked improvement in protein intake in group 1 (63.1 ± 12.1) when compared with group 2 (53.1 ± 13.4) was statistically significant (p = 0.008). A subset analysis showed that non-vegetarians (consuming meat and dairy products) between the groups showed that group 1 had a significantly higher calorie (p = 0.004) and protein (p = 0.0001) intake compared to individuals in group 2. Following implementation of study's protocol, the goal of achieving ≥75% of the prescribed calories (p = 0.013) and protein (p = 0.0001) was significantly higher in group 1.

CONCLUSION

When compared to the standard prescription, an individualized protocol to diagnose, stratify the severity of malnutrition early, and follow up by customized nutrition planning for patients helped to achieve nutritional targets more effectively. Inspite of patients' diversity in nutritional habits and reluctance to accept change, it is clear that a qualified and dedicated transplant nutrition team can successfully implement perioperative nutrition protocol to achieve better nutritional targets.

Factors related to increased resting energy expenditure in men with liver cirrhosis

OBJECTIVE

Hypermetabolism in cirrhosis is associated with a high risk of complications and mortality. However, studies about underlying mechanisms are usually focussed on isolated potential determinants and specific etiologies, with contradictory results. We aimed at investigating differences in nutrition, metabolic hormones, and hepatic function between hypermetabolic and nonhypermetabolic men with cirrhosis of the liver.

PATIENTS AND METHODS

We prospectively enrolled 48 male cirrhotic inpatients. We evaluated their resting energy expenditure (REE) and substrate utilization by indirect calorimetry, body composition by dual-energy X-ray absorptiometry, liver function, and levels of major hormones involved in energy metabolism by serum sample tests. Patients with ascites, specific metabolic disturbances, and hepatocellular carcinoma were excluded.

RESULTS

REE and REE adjusted per fat-free mass (FFM) were significantly increased in cirrhotic patients. Overall, 58.3% of cirrhotic patients were classified as hypermetabolic. Groups did not differ significantly in age, etiology of cirrhosis, liver function, presence of ascites, use of diuretics, β-blockers, or presence of transjugular intrahepatic portosystemic shunts. Hypermetabolic cirrhotic patients had lower weight, BMI (P<0.05), nonprotein respiratory quotient (P<0.01), leptin (P<0.05), and leptin adjusted per fat mass (FM) (P<0.05), but higher FFM% (P<0.05) and insulin resistance [homeostatic model assessment-insulin resistance (HOMA-IR)] (P<0.05). Only HOMA-IR, leptin/FM, and FFM% were independently related to the presence of hypermetabolism.

CONCLUSION

Hypermetabolic cirrhotic men are characterized by lower weight, higher FFM%, insulin resistance, and lower leptin/FM when compared with nonhypermetabolic men. HOMA-IR, FFM%, and leptin/FM were independently associated with hypermetabolism, and may serve as easily detectable markers of this condition in daily clinical practice.

Nutrition in Chronic Liver Disease

Protein-calorie malnutrition is a transversal condition to all stages of chronic liver disease. Early recognition of micro or macronutrient deficiencies is essential, because the use of nutritional supplements reduces the risk of complications. The diet of patients with chronic liver disease is based on a standard diet with supplements addition as necessary. Restrictions may be harmful and should be individualized. Treatment management should aim to maintain an adequate protein and caloric intake and to correct nutrient deficiencies. The large majority of patients with grade I/II hepatic encephalopathy can tolerate a regular diet. Protein restriction can aggravate malnutrition and is not recommended, except in cases of hepatic encephalopathy unresponsive to optimized therapy.

Gastrointestinal dysfunction in liver cirrhosis

Patients with liver cirrhosis exhibit several features of gut dysfunction which may contribute to the development of cirrhosis complications as well as have an impact on nutritional status and health-related quality of life. Gastrointestinal symptoms are common in cirrhosis and their pathophysiology probably involves factors related to liver disease severity, psychological distress, and gut dysfunction (e.g., increased gastric sensitivity to distension and delayed gut transit). They may lead to reduced food intake and, thus, may contribute to the nutritional status deterioration in cirrhotic patients. Although tense ascites appears to have a negative impact on meal-induced accommodation of the stomach, published data on gastric accommodation in cirrhotics without significant ascites are not unanimous. Gastric emptying and small bowel transit have generally been shown to be prolonged. This may be related to disturbances in postprandial glucose, insulin, and ghrelin levels, which, in turn, appear to be associated to insulin resistance, a common finding in cirrhosis. Furthermore, small bowel manometry disturbances and delayed gut transit may be associated with the development of small bowel bacterial overgrowth. Finally, several studies have reported intestinal barrier dysfunction in patients with cirrhosis (especially those with portal hypertension), which is related to bacterial translocation and permeation of intestinal bacterial products, e.g., endotoxin and bacterial DNA, thus potentially being involved in the pathogenesis of complications of liver cirrhosis.

Hyper- and hypometabolism are not related to nutritional status of patients on the waiting list for liver transplantation

BACKGROUND & AIMS

Metabolic disorders and malnutrition are well known conditions reported in patients with liver disease (LD), but the relationship between them are underexplored. So, the aim of this study was to assess the resting energy expenditure (REE) of these patients, identifying the prevalence of hyper- and hypometabolism. In addition, to evaluate whether malnutrition and clinical variables were associated with REE and metabolic disorders.

METHODS

The REE was measured by indirect calorimetry and predicted by the Harris and Benedict formula (REEHB). Nutritional status was assessed by different methods. The etiology, severity and complications of LD were also evaluated.

RESULTS

A total of 81 patients were assessed. The measured REE was 1587.5 ± 426.6 kcal. The REE was overestimated by the REEHB (REE:REEHB <0.8) in 7.4% and underestimated (REE:REEHB >1.2) in 24.7% of the patients. The REE was lower in malnourished patients (p < 0.05). However, hyper- and hypometabolism were not associated with nutritional status (p > 0.05). The REE and hypermetabolism were not associated with LD, but hypometabolic patients had a higher prevalence of Child C, and had higher values for MELD, INR and total bilirubin (p < 0.05). After multiple regression analyses, the REE was significantly associated (p < 0.05) with intracellular body water, arm muscle area and serum glucose. Serum glucose was only significantly associated (p < 0.05) with hypermetabolism, and INR with hypometabolism.

CONCLUSION

Changes in resting metabolism are present but not universal. The hypermetabolism was associated with extrahepatic factors, and hypometabolism with the severity of LD. Under these conditions in the clinical setting, calculated energy requirements using the HB formula should be adjusted.

The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus

Nitrogen metabolism plays a major role in the development of hepatic encephalopathy (HE) in patients with cirrhosis. Modulation of this relationship is key to the management of HE, but is not the only nutritional issue that needs to be addressed. The assessment of nutritional status in patients with cirrhosis is problematic. In addition, there are significant sex-related differences in body composition and in the characteristics of tissue loss, which limit the usefulness of techniques based on measures of muscle mass and function in women. Techniques that combine subjective and objective variables provide reasonably accurate information and are recommended. Energy and nitrogen requirements in patients with HE are unlikely to differ substantially from those recommended in patients with cirrhosis per se viz. 35-45 kcal/g and 1.2-1.5g/kg protein daily. Small meals evenly distributed throughout the day and a late-night snack of complex carbohydrates will help minimize protein utilization. Compliance is, however, likely to be a problem. Diets rich in vegetables and dairy protein may be beneficial and are therefore recommended, but tolerance varies considerably in relation to the nature of the staple diet. Branched chain amino acid supplements may be of value in the occasional patient intolerant of dietary protein. Increasing dietary fiber may be of value, but the utility of probiotics is, as yet, unclear. Short-term multivitamin supplementation should be considered in patients admitted with decompensated cirrhosis. Hyponatremia may worsen HE; it should be prevented as far as possible and should always be corrected slowly.

CONCLUSION

Effective management of these patients requires an integrated multidimensional approach. However, further research is needed to fill the gaps in the current evidence base to optimize the nutritional management of patients with cirrhosis and HE.

Low fat intake is associated with pathological manifestations and poor recovery in patients with hepatocellular carcinoma

BACKGROUND

This study aimed to clarify whether dietary deviation is associated with pathological manifestations in hepatocellular carcinoma (HCC) patients.

METHODS

Dietary intake was estimated in 35 HCC cases before and after hospitalization by referencing digital camera images of each meal. Pathological conditions were evaluated in nitrogen balance, non-protein respiratory quotient (npRQ), neuropsychiatric testing and recovery speed from HCC treatment.

RESULTS

On admission, nitrogen balance and npRQ were negative and less than 0.85, respectively. Five patients were judged to have suffered from minimal hepatic encephalopathy that tended to be associated with a lowered value of npRQ (p = 0.082). The energy from fat intake showed a tendency of positive correlation with npRQ (p = 0.11), and the patients with minimal hepatic encephalopathy took significantly fewer energy from fat (p = 0.024). The energy difference from fat between diets at home versus those in the hospital showed a significant positive correlation with npRQ change after admission (p = 0.014). The recovery speed from invasive treatments for HCC showed a significant negative correlation with npRQ alteration after admission (p = 0.0002, r = -0.73).

CONCLUSIONS

These results suggest the lower fat intake leads to deterioration of energy state in HCC patients, which associates with poor recovery from invasive treatments and various pathological manifestations.

Accuracy and preference of measuring resting energy expenditure using a handheld calorimeter in healthy adults

BACKGROUND

Accurate estimates of energy expenditure are required in clinical nutrition in order to determine the requirements of individuals and to inform feeding regimes. Calorimetry can provide accurate measurements but is often impractical in clinical or community settings; prediction equations are widely used to estimate resting energy expenditure (REE) but have limited accuracy. A portable, self-calibrating, handheld calorimeter (HHC) may offer an alternative way of determining REE. The aim of the study was to evaluate whether estimates of REE derived using an HHC are closer to accurate measurements than values calculated using selected prediction equations.

METHODS

REE was measured in 36 healthy adults aged 21-58 years using a flow-through indirect calorimeter (FIC) and HHC. Estimated REE was calculated using three predictive equations (Harris & Benedict; Schofield; Henry). Differences in REE between the 'gold standard' values derived using the FIC and those derived using the HHC and equations were examined using paired t-tests and Bland Altman plots.

RESULTS

Mean REEHHC was significantly lower than mean REEFIC [4556 ± 1042 kJ (1089 ± 249 kcal) versus 6230 ± 895 kJ (1489 ± 214 kcal), P = 0.000] and also significantly lower than mean values calculated using all three equations. The mean difference between REEHHC and REEFIC [1674 ± 908 kJ (400 ± 217 kcal)] was significantly greater (P = 0.000) than the mean differences between the values calculated using the three prediction equations [272 ± 490 kJ (65 ± 117 kcal) (Harris-Benedict), 264 ± 510 kJ (63 ± 122 kcal) (Schofield), 84 ± 502 kJ (20 ± 120 kcal) (Henry)].

CONCLUSIONS

The HHC provides estimates of REE in healthy people that are less accurate than those calculated using the prediction equations and so does not provide a useful alternative.

Compound Pollen Protein Nutrient Increases Serum Albumin in Cirrhotic Rats

Background

Malnutrition, especially protein-calorie malnutrition, is common in patients with liver cirrhosis. When in the status of malnutrition, the complications increase, liver function deteriorates, and the prognosis of patients with liver cirrhosis worsens. Hence, nutritional support and treatment is essential in patients with liver cirrhosis. Previous studies suggested that compound nutrition based on pollen can improve liver function, and can be a basic nutrient for patients with liver cirrhosis. However, the nutritional support based on pollen for malnutrition of cirrhotic patients needs to be further evaluated. In this study, we investigated the nutritional support of Noveliver, a new compound pollen protein nutrient, in the cirrhotic rats induced by carbon tetrachloride (CCl₄).

Methods

The cirrhotic rats induced by CCl₄ were treated with Noveliver in different doses, and treated with a regular compound pollen nutrient, untreated cirrhotic rats and normal rats were used as controls. Serum albumin were measured before and after the nutritional treatment in each group. At the same time, liver function, cytokines and pathological changes were also determined.

Results

In the second week of nutritional treatment, the levels of serum albumin in normal control group, low dose noveliver group, high dose noveliver group, compound protein pollen group and spontaneous recovery group were 35.67 ± 1.42, 33.07 ± 1.27, 32.27 ± 1.50, 30.53 ± 0.25, 24.53 ± 3.56 (g/L), respectively, the differences among the groups were significant (F = 14.007, P = 0.000); The levels of serum albumin in low dose Noveliver group, high dose Noveliver group and the compound protein pollen group were higher than that in the spontaneous recovery group (P = 0.000, 0.001, 0.003, respectively). In the second week of nutritional treatment, the serum levels of HGF in normal control group, low dose Noveliver group, high dose Noveliver group, compound protein pollen group and spontaneous recovery group were 101.55 ± 0.87, 94.62 ± 8.80, 98.94 ± 3.68, 78.77 ± 21.79, 39.52 ± 14.03 (pg/ml), respectively, the differences among the groups were significant (F = 11.12, P = 0.002); the levels of HGF in low dose Noveliver group, high dose Noveliver group and the compound protein pollen group were higher than that in spontaneous recovery group (P = 0.001, 0.000, 0.005). Histological results showed that the fibrosis in spontaneous recovery group was severer than those in low dose Noveliver group, high dose Noveliver group and compound protein pollen group.

Conclusions

Our data show that the both the Noveliver and the compound pollen protein nutrient increase the serum albumin and ameliorate malnutrition in cirrhotic rats; the recovery of serum albumin might be related to the hepatic damage repair and liver regeneration.

Resting energy expenditure and substrate metabolism in Chinese patients with acute or chronic hepatitis B or liver cirrhosis

OBJECTIVE

Patients with liver disease usually have an imbalanced nutrient and energy metabolism that leads to malnutrition and seriously affects their prognosis. Therefore, it is of great clinical interest to understand the resting energy expenditure (REE) and oxidation rates of glucose, fat, and protein in these patients.

METHODS

A total of 315 patients with liver diseases caused by hepatitis B virus were categorized into three groups: 20 acute hepatitis patients, 142 chronic hepatitis patients and 153 liver cirrhosis patients. The REE and the oxidation rates of glucose, fat and protein were assessed by indirect heat measurement. Energy intake data were also collected which were compared with the REE results.

RESULTS

The REE per kg (REE/kg) were 27.34 ± 5.46 kJ/kg, 21.67 ± 5.01 kJ/kg and 19.07 ± 4.45 kJ/kg in acute, chronic hepatitis and liver cirrhosis patients (p=0.000), respectively. Respiratory quotient (RQ) tended to be lower in patients with chronic hepatitis and liver cirrhosis than that in acute hepatitis patients (p=0.023). Energy, protein and carbohydrate intakes were lower in liver cirrhosis patients.

CONCLUSION

These data demonstrated that Chinese patients with chronic hepatitis B and liver cirrhosis had lower energy expenditure and abnormal substrate metabolism. Patients with chronic hepatitis and cirrhosis had a higher protein oxidation rate and a lower carbohydrate oxidation rate compared with acute hepatitis patients.

ESPEN Guidelines on Parenteral Nutrition: hepatology

Parenteral nutrition (PN) offers the possibility to increase or to ensure nutrient intake in patients, in whom sufficient nutrition by oral or enteral alone is insufficient or impossible. Complementary to the ESPEN guideline on enteral nutrition of liver disease (LD) patients the present guideline is intended to give evidence-based recommendations for the use of PN in LD. For this purpose three paradigm conditions of LD were chosen: alcoholic steatohepatitis (ASH), liver cirrhosis and acute liver failure. The guideline was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was presented on the ESPEN website and visitors' criticism and suggestions were welcome and included in the final revision. PN improves nutritional state and liver function in malnourished patients with ASH. PN is safe and improves mental state in patients with cirrhosis and severe HE. Perioperative (including liver transplantation) PN is safe and reduces the rate of complications. In acute liver failure PN is a safe second-line option to adequately feed patients in whom enteral nutrition is insufficient or impossible.

Fasting and postprandial plasma ghrelin levels are decreased in patients with liver failure previous to liver transplantation

Anorexia is a problem of paramount importance in patients with advanced liver failure. Ghrelin has important actions on feeding and weight homeostasis. Concentrations of ghrelin are controversial in liver cirrhosis. Our aim was to study fasting ghrelin and their response to an oral glucose tolerance test (OGTT) in liver failure patients and normal subjects.

METHODS

We included 16 patients with severe liver failure prior to liver transplantation. As a control group we included 10 age- and BMI-matched healthy subjects. After an overnight fast, 75 g of oral glucose were administered; glucose, insulin, and ghrelin were obtained at baseline and at times 30, 60, 90, and 120 min, respectively.

RESULTS

Fasting ghrelin (median and range) were statistically significantly lower for patients compared to the controls, 527 (377-971) pg/ml vs. 643 (523-2163) pg/ml, P = 0.045, for patients and controls, respectively. The area under the curve for total ghrelin post-OGTT were lower in end-stage liver failure patients than in the control group, 58815 (44730-87420) pg/ml min vs. 76560 (56160-206385) pg/ml min, for patients and controls, respectively, P = 0.027.

CONCLUSIONS

Ghrelin levels are significantly decreased both fasting and post-OGTT in patients with liver failure candidates for transplantation. Decreased ghrelin levels could contribute to anorexia in patients with cirrhosis.

Improving clinical outcome in patients with intestinal failure using individualised nutritional advice

BACKGROUND

Patients with intestinal failure are required to adhere to a complex regimen. Written information may increase knowledge leading to improvements in clinical outcomes. The present study aimed to evaluate the effectiveness of nutrition advice incorporating the use of a booklet.

METHODS

Each patient completed a questionnaire evaluating their knowledge of the regime and quality of life and kept a diet and gastrointestinal output diary. The diary was assessed and they were given the booklet with a verbal explanation tailored to individual requirements. The booklet explained the causes of intestinal failure, diet and fluid recommendations in relation to intestinal anatomy, information on medications and long-term monitoring. Patients were reassessed at their next appointment using the same tools. The primary endpoint was an improvement in knowledge. Secondary endpoints were an improvement in oral nutritional intake, nutritional status, quality of life and the content of home parenteral nutrition.

RESULTS

Forty-eight patients completed the study. Knowledge improved significantly after dietetic intervention in association with the provision of the booklet (P < 0.001). Oral energy (P = 0.04) and fat (P = 0.003) intake increased with an improvement in body mass index (P = 0.02). Patients on home parenteral nutrition showed a reduction in parenteral energy (P = 0.02), nitrogen (P = 0.003), volume (P = 0.02) and frequency (P = 0.003).

CONCLUSIONS

A booklet for patients with intestinal failure in conjunction with personalised dietary counselling improves knowledge and clinical outcomes.

Decreased hepatic RBP4 secretion is correlated with reduced hepatic glucose production but is not associated with insulin resistance in patients with liver cirrhosis

OBJECTIVE

Patients with liver cirrhosis have a high incidence of insulin resistance and diabetes. This study was designed to determine circulating levels and hepatic production of retinol-binding protein 4 (RBP4) in relation to parameters of hepatic and systemic metabolism in patients with liver cirrhosis.

DESIGN AND METHOD

Circulating RBP4 levels were measured in 19 patients with liver cirrhosis at different clinical stages of the disease and in 20 age-, sex- and body mass index (BMI)-matched controls. Hepatic production rates of RBP4 and glucose were assessed by measuring the arterial hepatic venous concentration difference together with hepatic blood flow. Insulin resistance was determined by the Quantitative Insulin Sensitivity Check Index (QUICKI) and the homeostasis model assessment of insulin resistance (HOMA-IR), energy expenditure by indirect calorimetry and body composition by bioelectrical impedance analysis (BIA).

RESULTS

Compared with controls, RBP4 levels in cirrhosis were decreased (8.1 +/- 1.8 vs. 22.6 +/- 2.4 mg/l, P < 0.001) due to decreased hepatic production (P < 0.05). RBP4 correlated with hepatic protein synthesis capacity (P < 0.01), but not with insulin resistance, energy expenditure, BMI or body fat mass. Plasma RBP4 correlated with hepatic glucose production (P < 0.05).

CONCLUSIONS

These data demonstrate that RBP4 in cirrhosis (i) is decreased due to reduced hepatic production, (ii) is not associated with insulin resistance, and (iii) might have a beneficial role by decreasing hepatic glucose production and could thus also be regarded as a hepatokine.

Evaluation of nutritional status of nonhospitalized patients with liver cirrhosis

BACKGROUND

[corrected] Protein-calorie malnutrition is a frequent finding in patients with chronic liver disease, but investigations of nutritional status have been rarely performed in individuals seen at outpatient clinics

AIM

To evaluate the nutritional status of patients with alcoholic and nonalcoholic cirrhosis, attended for the first time at a reference outpatient clinic for liver diseases.

PATIENTS AND METHODS

A total of 300 consecutive patients attended at the outpatient clinics of a reference center for liver diseases were investigated. Anthropometric evaluation was performed by the usual parameters: triceps skinfold, arm circumference and arm muscle circumference. Biochemical parameters included creatinine/height index, serum albumin and lymphocytes count. The nutritional diagnosis was based on the PCM score proposed by Mendenhall et al. Food intake was retrospectively evaluated using 24-hour dietary recall data.

RESULTS

About 71% of the patients studied were chronic alcohol abusers, whereas in 29% cirrhosis was of nonalcoholic etiology. Independently of the disease etiology 75.3% of the patients showed some degree of protein-calorie malnutrition, which was moderate or severe in 38.3% of them. More advanced protein-calorie malnutrition degrees were associated with lower energy and protein intake. The prevalence of moderate or severe protein-calorie malnutrition was higher in patients classified as Child-Pugh C than in patients classified as Child-Pugh A (21% x 58%, respectively). Regarding sexual differences, fat reserves, evaluated by triceps skinfold, were more depleted in females than in males (48.6% x 26.6%) regardless of the etiology of the cirrhosis, whereas muscle reserves (arm muscle circumference) were more depleted in males (43.4% x 13.4%) regardless of the etiology of cirrhosis. In contrast, cirrhosis of alcoholic etiology was determinant in reducing arm muscle circumference in females (20% x 9.1%)

CONCLUSIONS

These data highlight the high prevalence of protein-calorie malnutrition occurring early in the natural history of the disease and accompanying functional hepatic deterioration. In addition, attention should be paid to the different gender patterns of response to protein-calorie malnutrition in these patients.

Liver function test results predict nutritional status evaluated by arm anthropometric indicators

OBJECTIVES

To compare the anthropometric indicators based on weight and height with the anthropometric indicators based on arm measurements and to predict the anthropometric nutritional status with liver function tests (LFTs) in children with chronic liver disease (CLD).

PATIENTS AND METHODS

A cross-sectional study in a referral pediatric hospital enrolled 79 children with CLD (mean age 72.6 +/- 61.8 months, 54% female). An independent variable of LFT was used to determine the outcome variable of nutritional status. Anthropometric indicators of height versus age, weight versus height, head circumference versus age, and arm indicators versus age were analyzed with Pearson correlation, the determination coefficient r, and multiple regression.

RESULTS

A total of 44.3% of patients studied had growth impairment. The anthropomorphic indicator of weight for height identified malnutrition in 11.4%, compared with 43% identified by mid- to upper arm circumference (MUAC) and 40.5% identified with total arm area. MUAC (P < 0.001), total arm circumference (P < 0.001), arm muscle area (P = 0.009), and arm fat area (P = 0.023) identified more cases of z score less than -2 SD than weight/height. The presence of ascites misled weight-for-height measurements. Conjugated bilirubin and albumin had significant correlations with almost all of the anthropometric indicators. Alkaline phosphatase correlated significantly with all of the arm anthropometric indicators. A regression analysis led to 7 prediction models; the highest prediction of z score less than -2 SD was with triceps skinfold and conjugated bilirubin, albumin, and gamma-glutamyltransferase; height-for-age z score less than -2 SD was predicted by measurements of conjugated bilirubin, prothrombin time, and alanine aminotransferase.

CONCLUSIONS

The data presented underline the correlation between the liver damage severity evaluated by LFT and the nutritional status estimated by anthropometric indicators. In our view these observations reflect the close relationship between liver function and the degree of liver damage to growth and current nutritional status.

Body composition, muscle function, and energy expenditure in patients with liver cirrhosis: a comprehensive study

BACKGROUND

Data describing the nutritional status of patients with liver cirrhosis of diverse origin, as assessed by direct body-composition methods, are limited.

OBJECTIVE

We sought to provide a comprehensive assessment of nutritional status and metabolic activity in patients with liver cirrhosis by using the most accurate direct methods available.

DESIGN

Two hundred sixty-eight patients (179 M, 89 F; x +/- SEM age: 50.1 +/- 0.6 y) with liver cirrhosis underwent measurements of total body protein by neutron activation analysis, of total body fat and bone mineral by dual-energy X-ray absorptiometry, of resting energy expenditure by indirect calorimetry, of grip strength by dynamometry, and of respiratory muscle strength by using a pressure transducer. Dietary intakes of energy and protein were assessed and indexed to resting energy expenditure and energy intake, respectively.

RESULTS

Significant protein depletion, seen in 51% of patients, was significantly (P<0.0001) more prevalent in men (63%) than in women (28%). This sex difference occurred irrespective of disease severity or origin. The prevalence of protein depletion increased significantly (P<0.0001) with disease severity. Protein depletion was associated with decreased muscle function but not with lower energy and protein intake. Energy intake was significantly (P=0.002) higher in men than in women, whereas protein intakes did not differ significantly (P=0.12). Hypermetabolism, seen in 15% of patients, was not associated with sex, origin or severity of disease, protein depletion, ascites, or presence of tumor.

CONCLUSIONS

Poor nutritional status with protein depletion and reduced muscle function was a common finding, particularly in men, and was not related to the presence of hypermetabolism or reduced energy and protein intakes. The greater conservation of protein stores in women than in men warrants further investigation.

Altered postprandial glucose, insulin, leptin, and ghrelin in liver cirrhosis: correlations with energy intake and resting energy expenditure

BACKGROUND

Liver cirrhosis is associated with reduced energy intake and increased resting energy expenditure.

OBJECTIVE

We aimed to investigate the possible role of glucose, insulin, leptin, and ghrelin in the pathogenesis of these alterations.

DESIGN

Nutritional status, energy intake, resting energy expenditure, and fasting glucose, insulin, and leptin were assessed in 31 patients with cirrhosis. Postprandial glucose, insulin, C-peptide, leptin, and ghrelin responses were studied in a subgroup of patients after a standard meal. Ten healthy subjects served as controls.

RESULTS

Patients with cirrhosis had a lower energy intake (P < 0.05), higher resting energy expenditure (P < 0.05), higher fasting leptin (P < 0.05), and higher insulin resistance (P < 0.001) than did the healthy control subjects. In the patients with cirrhosis, fasting leptin was negatively correlated with resting energy expenditure (r = -0.38, P < 0.05) but not with energy intake. In control subjects, leptin was negatively correlated with energy intake (r = -0.72, P < 0.05) but not with resting energy expenditure. The patients with cirrhosis had higher postprandial glucose (P < 0.001) and lower ghrelin (P < 0.05) concentrations at 4 h postprandially than did the control subjects. The increase in ghrelin from its minimal postmeal value to 4 h postmeal was negatively correlated (r = -0.66, P = 0.014) with weight loss in the patients with cirrhosis. Energy intake was negatively correlated (r = -0.42, P < 0.01) with the postprandial increase in glucose.

CONCLUSIONS

In cirrhosis, altered postprandial glucose and ghrelin are associated with reduced energy intake and weight loss, respectively, and the effects of leptin on energy intake and expenditure seem to be altered. Insulin resistance might be involved in these altered postprandial responses.

Nutrition in alcoholic liver disease

Liver disease secondary to alcohol ranges from alcoholic fatty liver disease to acute hepatitis to cirrhotic liver disease. It is imperative that alcohol be discontinued to allow for any potential improvement in liver function, with most benefit being seen in the early stages of the disease. Alcoholic liver disease has a profound effect on nutrient intake, nutrition status, and metabolism, contributing to a high prevalence of malnutrition in this population. Early intervention with nutrition therapy may improve response to treatment, alleviate symptoms, and improve quality and quantity of life. In this review, nutrition assessment parameters and medical nutrition therapy goals for alcoholic liver disease are discussed.

Nutrition for the liver transplant patient

Patients with end-stage liver disease (ESLD) frequently have diverse abnormalities of carbohydrate, lipid, and protein metabolism that cause progressive deterioration of their clinical condition and lead to malnutrition. Malnutrition is almost universally present in patients with ESLD undergoing liver transplantation and has been associated with increased morbidity and mortality. It is essential to identify and correct nutritional deficiencies in this population and provide an adequate nutritional support during all phases of liver transplantation. In conclusion, this article reviews the etiologic factors, prevalence, assessment and management guidelines of nutritional disorders seen in patients with ESLD undergoing liver transplantation.

Basal energy expenditure and diet- induced modifications to thermogenesis in short bowel syndrome

BACKGROUND & AIM

The influence of food intake on diet-induced thermogenesis, in the absence of parenteral nutrition, has not been assessed in short bowel syndrome (SBS) patients. We studied basal energy expenditure (BEE) and diet-induced thermogenesis in SBS patients (n=8) and paired healthy adult volunteer controls (n=8).

METHODS

Energy expenditure was measured by indirect calorimetry (IC) before and after control diet intake. All study participants received oral control diet randomly given in 3 doses (A=1.0, B=1.5 and C=2.0)x1/6 of BEE calories. Bioelectric impedance was assessed. Pairing criteria for controls were: age, sex, body mass index.

RESULTS

No significant differences were found between SBS and paired healthy control groups in relation to absolute BEE (P=0.146) and when it was adjusted for body mass index, lean and fat body mass (P=0.861, 0.208 and 0.574, respectively). All diets promoted thermogenesis in both groups. The interaction between the control diet (A, B and C) and SBS and healthy control groups for diet induced thermogenesis presented a significant difference (P=0.026). When comparing groups (SBS vs healthy controls) in relation to the control diet (B and C) we observed: P=0.030 and 0.004, respectively.

CONCLUSION

In patients with SBS it was observed that: (1) BEE measured by IC in absolute values or adjusted by lean body mass is similar to healthy control group; (2) Diet-induced thermogenesis was lower than the healthy control group for higher caloric diets (B and C).

[Nutritional assessment in patients with cirrhosis: the use of indirect calorimetry]

BACKGROUND

Malnutrition is frequent in cirrhotic patients, and its assessment is difficult. Functional assessment through a dynamometer is a simple method and could minimize these drawbacks. Harris-Benedict prediction formulae estimates the resting energy expenditure but has not been validated for this population. One alternative is the use of indirect calorimetry.

AIM

To assess nutritional status in cirrhotic patients and estimates the resting energy expenditure through indirect calorimetry and compares it to Harris-Benedict.

PATIENTS AND METHODS

Thirty four adult hepatitis C cirrhotic outpatients were studied, classified by Child-Pugh and model of end-stage liver disease score. The resting energy expenditure was predicted through Harris-Benedict and measured by indirect calorimetry. Nutritional assessment was done through anthropometry, subjective global assessment, hand-grip strength and a 3-day recall.

RESULTS

Fifteen (44.2%) were Child-Pug A, 12 (35.3%) B and 7 (20.6%) C, and 33 (97.1%) had model of end-stage liver disease scores less than 20. The resting energy expenditure predicted was higher than the measured (Harris-Benedict 1404.5 +/- 150.3 kcal; indirect calorimetry 1059.9 +/- 309.6 kcal). The prevalence of malnutrition varied between methods (body mass index, muscle arm circumference, subjective global assessment, triceps skinfold thickness and hand-grip strength: 0; 5.9; 17.6; 35.3 and 79.4%, accordingly). Calories and proteins intake were 80% and 85% of recommended amounts and there was inadequate intake of calcium, magnesium, iron and zinc.

CONCLUSION

Malnutrition was frequent and hand-grip strength seemed to be the most sensitive method for its diagnosis. Calories and protein intakes were inadequate. Considering that the predicted resting energy expenditure was higher than the measured one and the need to offer higher caloric intake, the use of the predicting equation may replace indirect calorimetry.

Changing perspectives in the nutritional management of disease

There have been substantial changes in the nutritional management of many diseases in the last 20 years, which have been accompanied by a growing recognition of its importance. Many of the changes in clinical nutrition have been associated with the introduction of standards, clinical audit and the implementation of evidence-based practice, which has led to a re-evaluation of some established dietary interventions using a hierarchy-of-evidence approach. Although there are few randomised controlled trials on which to base such work, the examination of other, often less-robust, evidence has led to some traditional dietary interventions being modified. Examples in gastroenterology include the use of low-fat diets in gall bladder disease and the restriction of protein in hepatic encephalopathy, where the current evidence suggests that neither should be used routinely in clinical practice. Where therapeutic dietary restrictions are required, as with low-Na diets in ascites, there is very little information on how these restrictions influence total nutrient intake and, if intake is impaired, how the detrimental effects of an inadequate intake should be balanced with the therapeutic effects of restriction. Studies are required to ensure that nutritional interventions are not only effective but also free from undesirable side effects. The mode and timing of the delivery of nutritional support has also been re-evaluated and the benefits of early enteral feeding have been recognised. The delivery of dietary advice is a new area that is being considered, with practitioners in clinical nutrition using behaviour-change skills to facilitate optimum nutrition rather than simply providing patients with advice. For such developments to continue in clinical nutrition it is essential that all practice should be systematically evaluated and, where necessary, modified in the light of sound current research findings, and that gaps in our present knowledge base are identified and addressed.

Nutritional aspects of liver transplantation

Most adult and pediatric liver transplantation candidates present several metabolic disturbances that lead to malnutrition. Because malnutrition may adversely affect morbidity and mortality of orthotopic liver transplantation, it is very important to carefully assess the nutritional status of the waiting list patients. Pretransplant nutritional therapy -- enteral or parenteral -- may positively influence liver metabolism, muscle function, and immune status. Nutrition therapy should continue in the short- and also in the long-term post-transplant periods. For malnourished patients, early post-transplant enteral or parenteral nutrition have been useful in improving nutritional status. Finally, the metabolic and nutritional care of the liver transplant donor must be considered to reduce allograft dysfunction indices.

Current nutrition in liver disease

Malnutrition is common in severe liver disease. Assessment of malnutrition usually requires a subjective global assessment of the patient with a few additional tests that often include handgrip strength and arm-muscle circumference. The severity of liver disease correlates well with the severity of malnutrition, which has prognostic value. Malnutrition is multifactorial, is difficult to correct, and occurs in liver disease independently of the etiology of hepatic injury. Patients who have severe protein-calorie malnutrition require diets with high calorie and protein intake, even in the presence of hepatic encephalopathy. Some forms of complementary and alternative medicine are frequently used in patients with advanced liver disease, but supporting scientific data is needed. Obesity is detrimental to patients with advanced liver disease and is of greater concern in liver transplant candidates because it increases transplant-related morbidity. Data detailing the effects of aggressive nutritional support before transplantation are scarce, and more studies are needed.

Nutrition in hepatic failure and liver transplantation

Protein-energy malnutrition (PEM) is a common problem in patients with end-stage liver disease, and it is universally present in patients undergoing orthotopic liver transplantation. Although PEM is an independent risk factor for morbidity and mortality, it need not be considered an absolute contraindication for liver transplantation. The etiology of PEM in liver disease is multifactorial and includes decreased nutrient and calorie intake, alterations in intestinal malabsorption and/or maldigestion, and diverse abnormalities of carbohydrate, fat, and protein metabolism. This article reviews the prevalence of malnutrition, its pathophysiology, different modalities for assessment of body composition, and general guidelines for nutritional support in patients with liver disease and liver transplantation.

Elevated bound leptin correlates with energy expenditure in cirrhotics

BACKGROUND & AIMS

Leptin, found to be elevated in patients with liver cirrhosis, may contribute to the inadequate energy expenditure and malnutrition associated with a negative prognosis for these patients. Our aim was to characterize leptin components and their relationships to body composition, resting energy expenditure (REE), and substrate use in patients with posthepatic liver cirrhosis.

METHODS

Using specific radioimmunoassays, we measured free leptin and bound leptin in 27 cirrhotics and 27 matched control subjects. In the cirrhotic group, body composition and REE were determined.

RESULTS

Free leptin was not different in cirrhotics and control subjects and was related to body mass index (controls: r = 0.34, P < 0.05; cirrhotics: r = 0.55, P < 0.005) and to fat mass (cirrhotics: r = 0.76, P < 0.0001). Bound leptin was significantly higher in cirrhotic subjects than in controls (P < 0.001) and was related to REE x fat-free mass(-1) (r = 0.57, P < 0.005) or to the difference between measured and estimated REE (r = 0.55, P < 0.005).

CONCLUSIONS

Free leptin reflects fat mass in controls and cirrhotics. Increased serum leptin in cirrhotics is a result of increased bound leptin serum concentrations, which are positively related to energy expenditure. Moreover, bound leptin may be a useful marker for inadequate energy expenditure in patients with liver cirrhosis.