Body composition in nonalcoholic cirrhosis: the effect of disease etiology and severity on nutritional compartments

Body fat composition determines outcomes before and after liver transplantation in patients with cirrhosis

Cachexia occurs in late stages of liver cirrhosis, and a low-fat mass is potentially associated with poor outcome. This study compared different computed tomography (CT)-derived fat parameters with respect to its prognostic impact on the development of complications and death before and after liver transplantation. Between 2001 and 2014, 612 patients with liver cirrhosis without hepatocellular carcinoma listed for liver transplantation met the inclusion criteria, including abdominal CT scan (±200 days to listing). A total of 109 patients without cirrhosis served as controls. The subcutaneous fat index (SCFI), the paraspinal muscle fat index, and the visceral fat index were assessed at L3/L4 level and normalized to the height (cm² /m² ). Data were collected and analyzed retrospectively. Low SCFI was associated with a higher rate of ascites and increased C-reactive protein levels (p < 0.001). In addition, multivariate Cox regression analysis adjusting for sex, age, body mass index (BMI), and Model for End-Stage Liver Disease showed that decreasing SCFI was also associated with an increased risk of cirrhosis-related complications (p = 0.003) and death on the transplant wait list (p = 0.013). Increased paraspinal and visceral fat were not only positively correlated with creatinine levels (p < 0.001), BMI, and metabolic comorbidities (all p < 0.001) before transplantation, but also predictive for 1-year mortality after transplantation. Conclusion: The distribution of body fat is a major determinant for complications and outcome in cirrhosis before and after liver transplantation.

Late-Evening Carbohydrate and Branched-Chain Amino Acid Snacks Improve the Nutritional Status of Patients Undergoing Hepatectomy Based on Bioelectrical Impedance Analysis of Body Composition

Background

This prospective study measured body composition based on bioelectrical impedance analysis (BIA) in relation to preoperative and postoperative nutritional support and status in patients undergoing liver surgery.

Methods

Thirty-seven patients with impaired liver function (indocyanine green retention rate at 15 min >15%) undergoing hepatectomy for hepatocellular carcinoma or colorectal liver metastasis were enrolled. The control group (n = 10) received no nutritional supplementation. The late-evening snack (LES, n = 26) group received a 210-kcal snack comprising a carbohydrate with branched-chain amino acids for 2 weeks before surgery through to 12 weeks after surgery. BIA of body composition, including body cell mass and skeletal muscle volume, was performed.

Results

Although there was no sarcopenia based on the consensus report of the Asian Working Group 2 weeks before surgery, the skeletal muscle volumes in the control and LES groups were at the lower limit of the normal range. Body cell mass and skeletal muscle volume were significantly lower in the control group than in the LES group at 4 (p = 0.03) and 12 (p = 0.02) weeks after surgery.

Conclusion

Late-evening carbohydrate and branched-chain amino acid snack supplementation may improve nutritional status in patients with impaired liver function undergoing hepatectomy.

Effect of loop diuretics on skeletal muscle depletion in patients with liver cirrhosis

AIM

Sarcopenia, the loss of skeletal muscle mass, impairs prognosis of patients with liver cirrhosis. The aim of this study was to investigate the effect of loop diuretics, which are frequently used to treat hepatic edema/ascites, on skeletal muscle depletion and the prognosis in patients with liver cirrhosis.

METHODS

This retrospective study evaluated 226 patients with liver cirrhosis. The skeletal muscle cross-sectional area at the level of the third lumbar vertebra was measured using computed tomography. The relative change in skeletal muscle area per year (ΔSMA) was calculated, and the association between ΔSMA and therapeutic dosage of loop diuretics was examined.

RESULTS

The therapeutic dosage of loop diuretics was inversely correlated with ΔSMA by simple (r = -0.27, P < 0.0001) and multiple regression analyses (t = -3.07, P = 0.002). During a median follow-up period of 49 months, 82 patients died. Overall survival rates were lower in patients treated with loop diuretics at >20 mg than in those who received ≤20 mg (median, 66 vs. 97 months; P = 0.002). Multivariate analysis revealed that loop diuretics of >20 mg (hazard ratio [HR], 1.86; 95% confidence interval [CI], 1.03-3.24; P = 0.039) and ΔSMA of ≤-3.1% (HR, 3.87; 95% CI, 2.32-6.60; P < 0.0001) were independently associated with mortality.

CONCLUSIONS

A higher dose of loop diuretic use was associated with more rapid skeletal muscle depletion and poor survival in patients with liver cirrhosis, independent of the severity of liver disease.

Branched-chain amino acid-enriched nutrient increases blood platelet count in patients after endoscopic injection sclerotherapy

AIM

Protein and energy malnutrition is a severe problem for patients with liver cirrhosis (LC) and fasting often induces starvation which is a vitally important outcome. Dietary restriction is essential for endoscopic injection sclerotherapy (EIS) in patients with risky esophageal varices, thereby creating the possible exacerbation of nutritional state and inducing liver dysfunction. Whether EIS induces nutritional deficiency in LC patients and the effects of branched-chain amino acid (BCAA)-enriched nutrient are prospectively investigated.

METHODS

A total of 61 LC patients were randomly divided into an EIS monotherapy group (non-BCAA group, n = 31) and an EIS combined with BCAA therapy group (n = 30). Platelet count, blood chemistry and somatometry values were prospectively measured at five time points.

RESULTS

The platelet counts before treatment were at the same level in both groups (P = 0.72). Three months after treatment, the counts decreased in the non-BCAA group; however, they increased in the BCAA group (P = 0.019). Body mass index, triceps skin fold thickness and arm muscle circumference significantly decreased in both groups. The BCAA and tyrosine ratio value increased only in the BCAA group (P < 0.01). The skeletal muscle volume measured by InBody720 significantly decreased in the non-BCAA group (P < 0.001).

CONCLUSION

EIS induced protein-energy malnutrition, however, skeletal muscle volume was maintained by taking BCAA. Administration of BCAA had some effect in maintaining the nutritional state, and may improve the platelet count. Taking a greater amount of nutrients and shorter dietary restriction period or hospitalization was desirable.

Rapid skeletal muscle wasting predicts worse survival in patients with liver cirrhosis

AIM

Sarcopenia impairs the outcome of patients with liver cirrhosis independently of liver function reserves. The aim of this study was to investigate whether the rate of skeletal muscle wasting predicts mortality in cirrhotic patients.

METHODS

This retrospective study evaluated 149 cirrhotic patients who visited our hospital between March 2004 and September 2012. The skeletal muscle cross-sectional area at the level of the third lumbar vertebra was measured by computed tomography, from which the skeletal muscle index was obtained for diagnosis of sarcopenia. The relative change in skeletal muscle area per year (ΔSMA/y) was calculated in each patient. Cox proportional hazards regression analysis was performed to evaluate risk factors for mortality.

RESULTS

Of the 149 cirrhotic patients, 94 (63%) were diagnosed with sarcopenia. The median of ΔSMA/y in all patients was -2.2%. For patients in Child-Pugh class A, B and C, ΔSMA/y was -1.3%, -3.5% and -6.1%, respectively. During a median follow-up period of 39 months (range, 1-110), 45 patients (30%) died. The optimal cut-off value of ΔSMA/y for predicting mortality was -3.1%; the survival rate in patients with ΔSMA/y of -3.1% or less was significantly lower than in patients with ΔSMA/y of more than -3.1% (P < 0.0001). The multivariate Cox proportional hazards model found ΔSMA/y of -3.1% or less to be significantly associated with mortality in cirrhotic patients (hazard ratio = 2.73, 95% confidence interval = 1.43-5.44, P < 0.01).

CONCLUSION

ΔSMA/y is useful for predicting mortality in patients with liver cirrhosis. Management of skeletal muscle may contribute toward improving the outcome of cirrhotic patients.

Association between nutritional screening via the Controlling Nutritional Status index and bone mineral density in chronic liver disease of various etiologies

AIM

Bone density disorders are prevalent in patients with chronic liver disease (CLD), who commonly present with hepatic osteodystrophy. However, the relationship between nutritional status and bone mineral density (BMD) has been scarcely studied in CLD.

METHODS

This single-center, cross-sectional study included outpatients consecutively diagnosed with CLD during a 1.5-year period. The nutritional status was assessed with the Controlling Nutritional Status (CONUT) index; dual-energy X-ray absorptiometry scans and parameters of bone mineral metabolism were carried out. Bone fracture risk was estimated with the World Health Organization FRAX tool.

RESULTS

Among the 126 patients recruited (58.7% male), osteopenia and osteoporosis were present in 31.1% and 10.7%, respectively. The 10-year fracture risk was significantly higher among women. Malnutrition estimated with the CONUT index was present in 29.9% of patients and was significantly more frequent in cirrhotic patients, 63.4% of whom were malnourished. Malnutrition stage directly correlated with hepatic function as expressed by the Model for End-Stage Liver Disease index. A non-significant relationship between CONUT-assessed nutritional status and BMD was documented. 25-Hydroxyvitamin-D3 (25[OH]-D3) and fracture risk correlated positively with the CONUT stage, and total cholesterol had an inverse relationship with BMD.

CONCLUSION

Malnutrition assessed by the CONUT was very frequent in patients with liver cirrhosis. The CONUT score inversely correlated with liver function, while malnutrition stage directly correlated with BMD, fracture risk and 25(OH)-D3. Total cholesterol showed a negative association with BMD in this population.

The efficacy of nocturnal administration of branched-chain amino acid granules to improve quality of life in patients with cirrhosis

BACKGROUND

Nocturnal administration of branched-chain amino acid (BCAA) granules improves serum albumin levels in patients with cirrhosis. However, it is unclear whether or not this administration method can improve the patients' quality of life (QOL). In this study, we aimed to investigate the efficacy of BCAA granules, given nocturnally, in improving QOL in these patients.

METHODS

We performed a multicenter, randomized controlled trial examining the comparative effects of BCAA granules given orally for 3 months with daytime or nocturnal administration in patients with compensated cirrhosis. Health-related QOL was measured by a Japanese version of the questionnaire on subjective and objective symptoms, and the Short Form-8 (SF-8) questionnaire.

RESULTS

Twenty-one patients received BCAA granules three times a day (one sachet after each meal: the daytime group), and 16 patients received the granules twice a day (one sachet after breakfast, and two sachets before bedtime: the nocturnal group). Baseline characteristics did not differ between the groups (whole cohort: Child-Pugh grade A/B, 21/16; mean age, 68.2 years). There was no significant difference in any of the subjects revealed by the questionnaire regarding subjective or objective symptoms, or by the SF-8 between the daytime group and the nocturnal group after 3 months of treatment. The daytime group showed a significant effect on general health, vitality, social functioning, mental health, and role emotional as revealed on the SF-8. Conversely, the nocturnal group exhibited a significant decrease in the occurrence of muscle cramps in the legs (P = 0.014) and significantly improved Fisher's ratio after 3 months (P = 0.04).

CONCLUSIONS

Nocturnal administration of BCAA granules in patients with cirrhosis reduced the occurrence of muscle cramps in the leg but did not improve the patients' QOL.

Branched-chain amino acid-enriched nutrients improve nutritional and metabolic abnormalities in the early post-transplant period after living donor liver transplantation

BACKGROUND/PURPOSE

Malnutrition and metabolic disorder of patients undergoing living donor liver transplantation (LDLT) can affect post-transplant prognosis. The aim of this study was to establish whether perioperative usage of branched-chain amino-acid (BCAA)-enriched nutrients improve metabolic abnormalities of patients undergoing LDLT.

METHODS

We designed a randomized pilot study (UMIN registration number; 000004323). Twenty-five consecutive adult elective LDLT recipients were enroled and divided into two groups: the BCAA group (BCAA-enriched nutrients, n = 12) and the control group (standard diet, n = 13). Metabolic and nutritional parameters, including BCAA-to-tyrosine ratio (BTR), retinol binding protein (RBP), and prealbumin were regularly measured from 1 week before to 4 weeks after LDLT. Non-protein respiratory quotient (npRQ) was measured before and 4 weeks after LDLT.

RESULTS

BTR and RBP improved considerably in the BCAA group compared with the controls. npRQ significantly increased from 1 week before LDLT to 4 weeks after LDLT in the BCAA group (0.77 ± 0.05 to 0.84 ± 0.06, P = 0.002), but not in the control group (0.78 ± 0.04 to 0.81 ± 0.05).

CONCLUSIONS

Supplementation with BCAA-enriched nutrients might improve persistent nutritional and metabolic disorders associated with end-stage liver disease in the early post-transplant period, and consequently shorten the post-transplant catabolic phase after LDLT. A larger multicenter trial is needed to confirm these findings.

Reducing the load: the evolution and management of obesity and nonalcoholic steatohepatitis before liver transplantation

1. Obesity is common in patients with end-stage liver disease of any cause. 2. Obesity is associated with comorbidities that can affect liver transplant candidacy, such as metabolic syndrome (diabetes, hyperlipidemia, and hypertension), cardiovascular disease, pulmonary disorders (related to obstructive sleep apnea), renal dysfunction, and malignancies. 3. Nonalcoholic steatohepatitis is the only indication for transplantation that is increasing in frequency, and it may soon become the leading indication. 4. There is no set body mass index above which liver transplantation is contraindicated. Transplant candidacy and outcomes depend on the cumulative comorbidities of the individual patient. 5. Weight loss is an important component of metabolic syndrome management and is recommended before liver transplantation. 6. Bariatric surgery may be considered in carefully selected patients with well-compensated cirrhosis but is not recommended in patients with decompensated cirrhosis.

Short-term reductions in non-protein respiratory quotient and prealbumin can be associated with the long-term deterioration of liver function after transcatheter arterial chemoembolization in patients with hepatocellular carcinoma

BACKGROUND

Transcatheter arterial chemoembolization (TACE) is an effective treatment for hepatocellular carcinoma (HCC) that can cause deterioration of liver function. We aimed to make an early predictive model of long-term liver dysfunction after TACE.

METHODS

We performed a prospective cohort study involving 109 HCC patients who underwent TACE at Kobe University Hospital. Indirect calorimetry and blood biochemical examinations were performed before and 7 days after TACE. As an indicator of liver function, the Child's score was evaluated before and 3 months after TACE. Patients with and without Child's score deterioration were compared, and the independent risk factors for Child's score deterioration were statistically examined. An early predictive model of Child's score deterioration after TACE was developed using multivariate logistic regression.

RESULTS

Multivariate analyses showed that the non-protein respiratory quotient (npRQ) and prealbumin (preAlb) ratios (7 days after/before TACE) were independent determinants of Child's score deterioration (p = 0.039 and 0.020, respectively). Decreases of the npRQ and preAlb ratios were significantly related to increases of Child's score 3 months after TACE (p = 0.007 and 0.002, respectively). The following predictive model of Child's score deterioration was developed: exp(-6.383 × npRQ ratio - 3.038 × preAlb ratio + 7.755)/(1 + exp(-6.383 × npRQ ratio - 3.038 × preAlb ratio + 7.755)). The model discriminated well between patients with and without Child's score deterioration (area under the receiver operating curve [ROC]; AUC 0.713; 95% confidence interval [CI] 0.613-0.812). The optimal cut-off point for the Child's score was 0.449, and the sensitivity and specificity of the model were 57.1 and 79.1%, respectively.

CONCLUSIONS

Reductions in npRQ and preAlb 7 days after TACE were associated with the long-term deterioration of liver function. With our model, we were able to identify high-risk patients.

Nutritional status and liver transplantation

Chronic liver disease has a profound effect on nutritional status and undernourishment is almost universally present in patients with end-stage liver disease undergoing liver transplantation. In the last decades, due to epidemiological changes, a trend showing an increase in patients with end-stage liver disease and associated obesity has also been reported in developed countries. Nutrition abnormalities may influence the outcome after transplantation therefore, the importance to carefully assess the nutritional status in the work-up of patients candidates for liver transplantation is widely accepted. More attention has been given to malnourished patients as they represent the greater number. The subjective global nutritional assessment and anthropometric measurements are recognized in current guidelines to be adequate in identifying those patients at risk of malnutrition. Cirrhotic patients with a depletion in lean body mass and fat deposits have an increased surgical risk and malnutrition may impact on morbidity, mortality and costs in the post-transplantation setting. For this reason an adequate calorie and protein intake should always be ensured to malnourished cirrhotic patient either through the diet, or using oral nutritional supplements or by enteral or parenteral nutrition although studies supporting the efficacy of nutritional supplementation in improving the clinical outcomes after transplantation are still scarce. When liver function is restored, an amelioration in the nutritional status is expected. After liver transplantation in fact dietary intake rapidly normalizes and fat mass is progressively regained while the recovery of muscle mass can be slower. In some patients unregulated weight gain may lead to over-nutrition and may favor metabolic disorders (hypertension, hyperglycemia, hyperlipidemia). This condition, defined as 'metabolic syndrome', may play a negative role on the overall survival of liver transplant patients. In this report we review data on nutrition and liver transplantation.

Effect of an oral branched chain amino acid-enriched snack in cirrhotic patients with sleep disturbance

AIM

  Sleep is closely related to physical and mental health. Sleep disturbance is reported in patients without encephalopathy. We examined the relationship among cirrhotic symptoms, laboratory data and sleep disturbances. Next, we examined the influence of a branched chain amino acid (BCAA) supplement on sleep disturbance in cirrhotic patients.

METHODS

  We investigated a total of 21 patients at Nagasaki University Hospital from January to June 2009. We constructed questionnaire items for the evaluation of cirrhotic symptoms. The items, as major symptoms of cirrhotic patients, were as follows: hand tremor, appetite loss, muscle cramp of foot, fatigue, decreased strength, anxiety, abdominal fullness, abdominal pain and a feeling of low energy. We used the Epworth Sleepiness Scale (ESS) for the evaluation of daytime hypersomnolence. Energy supplementation with a BCAA snack was performed as a late evening snack (LES). All patients were assessed at the time of entry into the study, and at 4 and 8 weeks.

RESULTS

  It was found that BCAA snack, taken p.o. as an LES, improved the ESS for cirrhotic patients without encephalopathy. This beneficial result was recognized in the short term, 4 weeks after beginning of treatment. This study demonstrated the utility of BCAA supplementation for cirrhotic patients with sleep disturbance. However, the cirrhotic symptom-related score was positively relation with the Child-Pugh score at the time of patient entry, and we were unable to identify the item that related to ESS.

CONCLUSION

  A BCAA snack is a useful drug for cirrhotic patients who do not have any overt encephalopathy, but who suffered from sleep disturbance.

Protein nitration is associated with increased proteolysis in skeletal muscle of bile duct ligation-induced cirrhotic rats

Cirrhosis is characterized by skeletal muscle wasting. In this study, the effects of nitric oxide production on skeletal muscle protein nitration and degradation in cirrhosis were investigated. Cirrhosis was induced by bile duct ligation (BDL) in Sprague-Dawley rats for 4 weeks. The BDL-induced cirrhotic rats and sham-operated rats were then injected daily with either saline or N(G)-l-nitro-arginine methyl ester (l-NAME) for 7 days from week 4 to week 5, after which nitrite/nitrate, glutathione reduction, as well as protein nitration, ubiquitination, and degradation were assessed in skeletal muscle. Elevated muscular nitrite/nitrate concentrations, protein nitration, total ubiquitin conjugates, and degradation fragments of myosin heavy chain as well as diminished glutathione reduction levels were observed in BDL-induced cirrhotic rats as compared with controls. Administration of l-NAME for 1 week led to reduction of nitrite/nitrate levels; protein nitration was also decreased in the skeletal muscle. In addition, ubiquitination of muscular proteins and degradation of myosin heavy chain were significantly diminished after treatment of l-NAME. In conclusion, nitrosative stress occurred in the skeletal muscle of BDL-induced cirrhotic rats and may lead to increased proteolysis of muscle-specific structural proteins.

Cryptogenic cirrhosis: what are we missing?

Cryptogenic cirrhosis remains a common clinical condition although recent advances have allowed for a better understanding of underlying conditions and associations. The evolving terminology applied to this condition has resulted in some confusion and persistent variation among pathologists and clinicians. Typical patients are middle aged with only minor liver enzyme abnormalities. Presentations range from incidentally discovered cirrhosis to complications of advanced portal hypertension and hepatocellular cancer. Clinicopathologic analysis of these patients indicates that the leading causes include previously unrecognized nonalcoholic steatohepatitis, silent autoimmune hepatitis, non-B, non-C viral hepatitis, and occult past ethanol exposure. In this article, we review these associations as well as a proposed classification system for cryptogenic cirrhosis and other lesser known genetic and syndromic associations that warrant consideration when evaluating these individuals.

Body composition changes after transjugular intrahepatic portosystemic shunt in patients with cirrhosis

AIM: To investigate the effect of transjugular intrahepatic porto-systemic shunt (TIPS) on malnutrition in portal hypertensive cirrhotic patients.

METHODS: Twenty-one patients with liver cirrhosis and clinical indications for TIPS insertion were investigated before and 1, 4, 12, 52 wk after TIPS. For each patient we assayed body composition parameters [dry lean mass, fat mass, total body water (TBW)], routine liver and kidney function tests, and free fatty acids (FFA). Glucose and insulin were measured for the calculation of the homeostasis model assessment insulin resistance (HOMA-IR); liver function was measured by the galactose elimination capacity (GEC); the severity of liver disease was graded by model for end-stage liver disease (MELD).

RESULTS: Porto-systemic gradient decreased after TIPS (6.0 ± 2.1 mmHg vs 15.8 ± 4.8 mmHg, P < 0.001). Patients were divided in two groups according to initial body mass index. After TIPS, normal weight patients had an increase in dry lean mass (from 10.9 ± 5.9 kg to 12.7 ± 5.6 kg, P = 0.031) and TBW (from 34.5 ± 7.6 L to 40.2 ± 10.8 L, P = 0.007), as well as insulin (from 88.9 ± 49.2 pmol/L to 164.7 ± 107.0 pmol/L, P = 0.009) and HOMA-IR (from 3.36% ± 2.18% to 6.18% ± 4.82%, P = 0.023). In overweight patients only FFA increased significantly (from 0.59 ± 0.24 mmol/L to 0.93 ± 0.34 mmol/L, P = 0.023).

CONCLUSION: TIPS procedure is effective in lowering portal pressure in patients with portal hypertension and improves body composition without significant changes in metabolic parameters.

A snack enriched with oral branched-chain amino acids prevents a fall in albumin in patients with liver cirrhosis undergoing chemoembolization for hepatocellular carcinoma

Nutritional support may play an important role in management of liver cirrhosis (LC) associated with unresectable hepatocellular carcinoma (HCC). Total protein and albumin deteriorate in patients with LC undergoing trans-arterial chemoembolization (TACE). Therefore, in this study, we examined the hypothesis that short-term administration of branched-chain amino acids (BCAA) will prevent a fall in total protein and albumin in the perioperative period. The subjects were 56 patients who underwent TACE for HCC between 2004 and 2005 at Nagasaki University Hospital. The patients were randomly placed in the BCAA group (n = 28) or a control group (n = 28). The patients in the BCAA group consumed a snack containing 50 g of BCAA once a day at 10:00 pm starting 1 day before TACE and continuing until 2 weeks after TACE. A comparison of baseline and end point data showed greater decreases in the concentrations of total protein, albumin, cholinesterase, and total cholesterol and in the red blood cell count in the control group compared to the BCAA group. Ammonia levels decreased in the BCAA group and increased in the control group. Our findings indicate that a BCAA supplement taken orally as a late evening snack prevents suppression of liver function by TACE in patients with LC complicated with HCC during the 2-week period after TACE.

Myopathy and alterations in serum 3-methylhistidine in dogs with liver disease

Liver disease can influence the metabolism of various other organs. Regarding the influence of liver diseases on muscles, only a few studies done on people exist. The goal of our study was to investigate the influence of liver diseases on muscles in dogs. Twenty-eight dogs with different liver diseases were investigated in this study. The diagnosis of muscle alteration was based on electromyography (EMG), creatine kinase serum activity, 3-methylhistidine serum concentration and a muscle biopsy in some cases. Our results suggest that liver diseases in dogs can be accompanied with muscle alteration. 3-Methylhistidine serum concentration as a new parameter for muscle destruction in dogs was significantly increased compared to clinical healthy dogs and was comparable to those concentrations in dogs with histologically confirmed myopathy of different types. The differentiation of the liver diseases into severe hepatitis, moderate hepatitis and liver tumours showed a significant elevation of 3-methylhistidine serum concentration in cases of liver tumours (P=0.03) and a tendency in cases of severe hepatitis (P=0.07). Based on our study we can conclude that liver diseases have an influence on muscles in dogs and 3-methylhistidine could be a useful parameter for muscle destruction.

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.

Validation of body mass index for the diagnosis of malnutrition in patients with liver cirrhosis

OBJECTIVES

Simple clinical tools are needed to detect malnutrition in cirrhotic patients. We have validated optimal body mass index (BMI) cut-offs for the diagnosis of malnutrition in accordance with the importance of ascites.

METHODS

BMI, mid-arm muscle circumference (MAMC) and triceps skinfold thickness (TST) were measured before paracentesis in study (SP) and validation (VP) populations of 875 and 294 cirrhotic patients, respectively with no ascite (NA), mild (MA), tense ascites (TA) (NA/MA/TA: SP: 327, 270, 278; VP: 111, 69, 114). Preserved nutritional status (SP: 259; VP: 93), malnutrition including severe and moderate malnutrition (SP: 251 and 365; VP: 92 and 109) were defined from MAMC and TST measurements.

RESULTS

Optimal BMI cut-off values were 22, 23 and 25 kg/m2 in NA, MA and TA patients, respectively. In the whole SP and VP, sensitivities of these cut-offs were 86.2% and 89.1%, respectively; the corresponding negative predictive values (NPV) for the diagnosis of severe malnutrition were 92.3% and 93.2%; specificities and positive predictive values (PPV) were 87.7% and 89.9%, 92.7% and 93.6%, respectively for the diagnosis of malnutrition. In the entire VP, peripheral oedema did not change sensitivity and NPV of BMI cut-offs for the diagnosis of severe malnutrition and tended to increase specificity and PPV for the diagnosis of malnutrition. 96.7% of the malnourished TA patients in the VP before paracentesis were correctly identified after removal of ascites.

CONCLUSION

BMI is a reliable parameter to detect malnutrition in cirrhotic patients with the above mentioned cut-offs. Peripheral oedema and removal of ascites do not affect its diagnostic performance.

Stimulated resistin expression in white adipose of rats with bile duct ligation-induced liver cirrhosis: relationship to cirrhotic hyperinsulinemia and increased tumor necrosis factor-alpha

Resistin, an adipose-derived polypeptide hormone, is proposed as a candidate of insulin resistance, although its roles in inhibiting adipogenesis and in inflammation have also been suggested. Liver cirrhosis is characterized by elevated circulating proinflammatory cytokines, including tumor necrosis factor-alpha (TNF-alpha), hyperinsulinemia and insulin resistance. The study aimed to examine resistin expression and its association with insulin and TNF-alpha in a cirrhotic rat model using bile duct ligation (BDL). The BDL-induced cirrhotic rats showed significantly lower fat mass, insulin sensitivity and elevated plasma insulin and TNF-alpha compared to sham animals. In addition, epididymal TNF-alpha and resistin mRNA and protein levels were higher in cirrhotic rats. In normal control rats, in vivo insulin infusion and ex vivo administration of TNF-alpha to cultured fat pads increased resistin gene expression significantly. These results implied that hyperinsulinemia and increased TNF-alpha levels might upregulate adipose resistin gene in BDL-induced liver cirrhosis. Further study is necessary to document the role of resistin in metabolic abnormalities of liver cirrhosis.

Activation of ubiquitin-proteasome pathway is involved in skeletal muscle wasting in a rat model with biliary cirrhosis: potential role of TNF-alpha

Hepatic cirrhosis is associated with negative nitrogen balance and loss of lean body mass. This study aimed to identify the specific proteolytic pathways activated in skeletal muscles of cirrhotic rats. TNF-alpha can stimulate muscle proteolysis; therefore, a potential relationship between TNF-alpha and muscle wasting in liver cirrhosis was also evaluated. Cirrhosis was induced by bile duct ligation (BDL) in male adult Sprague-Dawley rats. mRNA and protein levels of various targets were determined by RT-PCR and Western blotting, respectively. The proteolytic rate was measured ex vivo using isolated muscles. Compared with sham-operated controls, BDL rats had an increased degradation rate of muscle proteins and enhanced gene expression of ubiquitin, 14-kDa ubiquitin carrier protein E2, and the proteasome subunits C2 and C8 (P < 0.01). The muscle protein levels of free ubiquitin and conjugated ubiquitin levels were also elevated (P < 0.01). However, there was no difference between the two groups with regard to cathepsin and calpain mRNA levels. Cirrhotic muscle TNF-alpha levels were increased and correlated positively with free and conjugated ubiquitin (P < 0.01). We conclude that the ubiquitin-proteasome system is involved in muscle wasting of rats with BDL-induced cirrhosis. TNF-alpha might play a role in mediating activation of this proteolytic pathway, probably through a local mechanism.

Effect of liver cirrhosis on body composition: evidence of significant depletion even in mild disease

BACKGROUND AND AIMS

Malnutrition is common in liver cirrhosis patients. However, it is under-diagnosed because liver disease affects the traditional nutritional assessment. An understanding of changes in body composition and the establishment of the tissue-loss pattern in liver cirrhosis patients could help practitioners to better manage malnutrition in this setting. The aims of this study were: to quantify body composition changes, to determine tissue loss pattern, and to assess the relation of these to the severity of hepatic dysfunction.

METHODS

Seventy-nine patients and 17 controls were studied. Total body water and extracellular water were measured using dilution techniques. Intracellular water and body cell mass were calculated from these parameters. Total body fat was obtained using absorptiometry.

RESULTS

Extracellular water was increased and intracellular water was decreased in patients. The two major compartments (body cell mass and body fat) were significantly reduced, mainly in patients with moderate and severe disease. However, significant losses occurred even in Child-Pugh class A patients. We established a tissue-loss pattern. In Child-Pugh class A patients body fat loss predominated. Child-Pugh class B patients had losses in at least one of the two compartments. Most Child-Pugh class C patients had simultaneous depletion in both compartments.

CONCLUSIONS

Liver cirrhosis was characterized by a significant reduction in body cell mass and body fat and by a redistribution of body water. Significant losses occurred even in patients with mild disease. There was a more pronounced loss of fat in the initial stages, followed by an accelerated loss of body cell mass in the advanced stages of liver cirrhosis.

Jejunal microvilli atrophy and reduced nutrient transport in rats with advanced liver cirrhosis: improvement by Insulin-like Growth Factor I

Background

Previous results have shown that in rats with non-ascitic cirrhosis there is an altered transport of sugars and amino acids associated with elongated microvilli. These alterations returned to normal with the administration of Insulin-Like Growth Factor-I (IGF-I). The aims of this study were to explore the evolution of these alterations and analyse the effect of IGF-I in rats with advanced cirrhosis and ascites. Thus, jejunal structure and nutrient transport (D-galactose, L-leucine, L-proline, L-glutamic acid and L-cystine) were studied in rats with ascitic cirrhosis.

Methods

Advanced cirrhosis was induced by CCl₄ inhalation and Phenobarbital administration for 30 weeks. Cirrhotic animals were divided into two groups which received IGF-I or saline during two weeks. Control group was studied in parallel. Jejunal microvilli were studied by electron microscopy. Nutrient transport was assessed in brush border membrane vesicles using ¹⁴C or ³⁵S-labelled subtracts in the three experimental groups.

Results

Intestinal active Na⁺-dependent transport was significantly reduced in untreated cirrhotic rats. Kinetic studies showed a decreased V_max and a reduced affinity for sugar and four amino acids transporters (expressed as an increased K_t) in the brush border membrane vesicles from untreated cirrhotic rats as compared with controls. Both parameters were normalised in the IGF-I-treated cirrhotic group. Electron microscopy showed elongation and fusion of microvilli with degenerative membrane lesions and/or notable atrophy.

Conclusions

The initial microvilli elongation reported in non ascitic cirrhosis develops into atrophy in rats with advanced cirrhosis and nutrient transports (monosaccharides and amino acids) are progressively reduced. Both morphological and functional alterations improved significantly with low doses of IGF-I.

Sensibilidade de indicadores da desnutrição protéico-energética em cirróticos com vários graus de disfunção hepatocelular

OBJETIVO: A sensibilidade de indicadores antropométricos e laboratoriais, na detecção da desnutrição protéico-energética de cirróticos foi estudada em 117 adultos, com gravidades (Child-Pugh), Child A (18), B (42) e C (57). RESULTADOS: Os indicadores antropométricos mais alterados foram: a circunferência braquial 61%, a prega cutânea tricipital 55% e a prega cutânea subescapular 53%, e os laboratoriais: albumina 93% e hemoglobina 90%. Com a combinação de indicadores circunferência braquial + prega cutânea subescapular + albumina ou hemoglobina, alcançaram-se 29% de déficit, valor idêntico ao da associação apenas de circunferência braquial + prega cutânea subescapular. Essa combinação (circunferência braquial e prega cutânea subescapular) detectou 63% de desnutrição protéico-energética, com predominância das formas moderada e grave em todos os graus Child. CONCLUSÃO: A desnutrição protéico-energética na cirrose hepática é predominantemente protéica, podendo ser caracterizada por indicadores laboratoriais (mais sensíveis) ou, com maior especificidade, pela circunferência braquial, embora inespecífica à discriminação da gravidade da desnutrição protéico-energética entre os grupos Child B e C.

Significance of branched chain amino acids as possible stimulators of hepatocyte growth factor

Amino acids can serve as regulatory molecules that modulate numerous cellular functions. Branched chain amino acids (BCAAs) are known to exert influences on cellular metabolism, amino acid transport, protein turn over, and gene expression. However, the mechanisms involved in the specific effect of BCAAs have not been clarified. BCAA supplementation therapy is a current treatment for patients with liver cirrhosis, therefore, specific BCAA activities should be examined. Hepatocyte growth factor (HGF) is considered to be a pleiotropic factor, and is reported to modulate gene expression and to stimulate the proliferation and functions of many cell types, including hepatocytes. A potential application of HGF for several types of diseases has been postulated. Here, we describe the potential of BCAAs as a therapeutic agent that acts through the induction of HGF production in the liver.

Different degrees of malnutrition and immunological alterations according to the aetiology of cirrhosis: a prospective and sequential study

OBJECTIVES

In this work we investigated how immunological dysfunction and malnutrition interact in alcoholic and viral aetiologies of cirrhosis.

METHODS

To investigate the matter, 77 cirrhotic patients divided in three aetiologies [Alcohol, HCV and Alcohol + HCV) and 32 controls were prospectivelly and sequentially studied. Parameters of humoral immunity (Components 3 and 4 of seric complement and immunoglobulins A M, G and E) and of cellular immunity (total leukocytes and lymphocytes in peripheral blood, T lymphocytes subpopulations, CD4+ and CD8+, CD4+/CD8+ ratio and intradermic tests of delayed hypersensitivity), as well as nutritional parameters: anthropometric measures, serum albumin and transferrin were evaluated.

RESULTS

Multiple statistical comparisons showed that IgM was higher in HCV group; IgG was significantly elevated in both HCV and Alcohol + HCV, whereas for the Alcohol group, IgE was found at higher titles. The analysis of T- lymphocytes subpopulations showed no aetiologic differences, but intradermic tests of delayed hypersensitivity did show greater frequency of anergy in the Alcohol group. For anthropometric parameters, the Alcohol +HCV group displayed the lowest triceps skinfold whereas creatinine--height index evaluation was more preserved in the HCV group. Body mass index, arm muscle area and arm fat area showed that differently from alcohol group, the HCV group was similar to control.

CONCLUSION

Significant differences were found among the main aetiologies of cirrhosis concerning immunological alterations and nutritional status: better nutrition and worse immunology for HCV and vice-versa for alcohol.

Growth hormone resistance in chronic heart failure and its therapeutic implications

BACKGROUND

In recent years the administration of recombinant human growth hormone (GH) has received great attention. This review compares the potential of this therapeutic intervention in heart failure with that in other diseases where wasting is commonly seen. The pathophysiologic importance of GH and insulin-like growth factor (IGF)-I in these conditions will be discussed.

METHODS AND RESULTS

Abnormalities of the GH-IGF-I axis play an important role in the development of cachexia in chronic illnesses. GH resistance is a major determinant of the wasting process, acting through several different mechanisms: increased catabolism, impaired anabolism, and enhanced apoptosis in peripheral tissues. GH therapy has been evaluated in chronic heart failure (CHF); acquired GH resistance may explain the general lack of therapeutic success in the majority of studies. The assessment of plasma levels of GH, IGF-I, and, in particular, GH binding protein may help to guide dosing of GH for CHF patients.

CONCLUSIONS

GH resistance might be overcome by use of intermittent or higher doses of GH, or alternatively by combining GH with IGF-I. Randomized studies of GH therapy in catabolic states, with targeted dosing and longer duration of treatment are required to fully assess the safety and efficacy of this treatment approach.

Nutritional supplementation with branched-chain amino acids in advanced cirrhosis: a double-blind, randomized trial

BACKGROUND & AIMS

The role of oral supplementation with branched-chain amino acids (BCAA) in advanced cirrhosis is far from settled. A nutritional approach might prevent progressive liver failure and improve nutritional parameters and quality of life.

METHODS

A multicenter, randomized study comparing 1-year nutritional supplementation with BCAA against lactoalbumin or maltodextrins was performed in 174 patients with advanced cirrhosis. Primary outcomes were the prevention of a combined end point (death and deterioration to exclusion criteria), the need for hospital admission, and the duration of hospital stay. Secondary outcomes were nutritional parameters, laboratory data and Child-Pugh score, anorexia, health-related quality of life, and need for therapy.

RESULTS

Treatment with BCAA significantly reduced the combined event rates compared with lactoalbumin (odds ratio, 0.43; 95% confidence interval, 0.19-0.96; P = 0.039) and nonsignificantly compared with maltodextrins (odds ratio, 0.51; 95% confidence interval, 0.23-1.17; P = 0.108). The average hospital admission rate was lower in the BCAA arm compared with control treatments (P = 0.006 and P = 0.003, respectively). In patients who remained in the study, nutritional parameters and liver function tests were, on average, stable or improved during treatment with BCAA and the Child-Pugh score decreased (P = 0.013). Also, anorexia and health-related quality of life (SF-36 questionnaire) improved. Long-term compliance with BCAA was poor.

CONCLUSIONS

In advanced cirrhosis, long-term nutritional supplementation with oral BCAA is useful to prevent progressive hepatic failure and to improve surrogate markers and perceived health status. New formulas are needed to increase compliance.

Body composition and components of energy expenditure in children with end-stage liver disease

BACKGROUND

Better understanding of body composition and energy metabolism in pediatric liver disease may provide a scientific basis for improved medical therapy aimed at achieving optimal nutrition, slowing progression to end-stage liver disease (ESLD), and improving the outcome of liver transplantation.

METHODS

Twenty-one children less than 2 years of age with ESLD awaiting liver transplantation and 15 healthy, aged-matched controls had body compartment analysis using a four compartment model (body cell mass, fat mass, extracellular water, and extracellular solids). Subjects also had measurements of resting energy expenditure (REE) and respiratory quotient (RQ) by indirect calorimetry. Nine patients and 15 control subjects also had measurements of total energy expenditure (TEE) using doubly labelled water.

RESULTS

Mean weights and heights were similar in the two groups. Compared with control subjects, children with ESLD had higher relative mean body cell mass (33 +/- 2% vs 29 +/- 1% of body weight, P < 0.05), but had similar fat mass, extracellular water, and extracellular solid compartments (18% vs 20%, 41% vs 38%, and 7% vs 13% of body weight respectively). Compared with control subjects, children with ESLD had 27% higher mean REE/body weight (0.285 +/- 0.013 vs 0.218. +/- 0.013 mJ/kg/24h, P < 0.001), 16% higher REE/unit cell mass (P < 0.05); and lower mean RQ (P < 0.05). Mean TEE of patients was 4.70 +/- 0.49 mJ/24h vs 3.19 +/- 0.76 in controls, (P < 0.01).

CONCLUSIONS

In children, ESLD is a hypermetabolic state adversely affecting the relationship between metabolic and nonmetabolic body compartments. There is increased metabolic activity within the body cell mass with excess lipid oxidation during fasting and at rest. These findings have implications for the design of appropriate nutritional therapy.

Increased serum leptin concentrations correlate with soluble tumour necrosis factor receptor levels in patients with cirrhosis

OBJECTIVE

Several reports have documented the involvement of hyerleptinaemia in malnutrition associated with liver cirrhosis. However, the mechanisms of elevated leptin levels remains unclear. Serum concentrations of tumour necrosis factor-alpha (TNF-alpha), and two soluble TNF receptors (sTNF-RI and sTNF-RII) are increased in patients with liver cirrhosis. In rodents, administration of TNF-alpha has been shown to stimulate plasma leptin concentration, suggesting that a cytokine-leptin link may mediate anorexia and weight loss during chronic inflammation. In this study, we investigate the potential interaction of the TNF-alpha system with leptin in the development of malnutrition in liver cirrhosis.

STUDY DESIGN

A total of 26 male patients with liver cirrhosis and 25 healthy people were recruited at an outpatient clinic at the Veterans General Hospital in Taiwan. Serum biochemistry and anthropometric measurement by bioelectrical impedance analysis were used to assess nutrition status, and immunoassay was used to determine serum leptin, TNF-alpha sTNF-RI and sTNF-RII concentrations.

RESULTS

In cirrhotic patients, the body fat mass (FM) and serum albumin levels were both lower than control subjects [15.8 (13.2-19.5) kg vs. 18.9 (16.2-20.1) kg; 35 (33-41) g/l vs. 43 (41-45) g/l, respectively; P < 0.05]. Serum TNF-alpha sTNF-RI and sTNF-RII were significantly elevated in cirrhotic patients compared to healthy controls [9.8 (7.2-13.5) ng/l vs. 4.3 (3.4-7.3) ng/l; 1682.1 (1344.8-2179.4) ng/l vs. 1319.6 (1037.7-1632.1) ng/l; 4462.2 (3748.5-5159.4) ng/l vs. 3559.8 (2506.9-3988.9 ng/l, respectively; P < 0.01] and correlated with disease severity (graded by Pugh-Child's scores). An inverse correlation was observed between circulating sTNF-RI and sTNF-RII to serum albumin levels (r =-0.42, r = -0.398; P < 0.05). The serum leptin levels in cirrhotic patients were significantly higher [6.0 (3.6-7.7) (g/l vs. 3.4 (2.9-4.3) (g/l; P < 0.01) and correlated with body FM (r = 0.52; P < 0.01]. Using a multiple linear regression analysis with leptin as dependent variable and FM and TNF-alpha, sTNF-R as independent variables, FM and serum sTNF-RI concentrations were found to predict independently the leptin levels in cirrhotic patients.

CONCLUSION

Our study demonstrated that serum levels of TNF-alpha, sTNF-RI, sTNF-RII and leptin were all elevated in cirrhotic patients. The severity of liver cirrhosis was an important factor for the activation of TNF-alpha system. The activated TNF-alpha system conjointly with hyperleptinaemia might mediate malnutrition in patients with liver cirrhosis.

Rapid measurement of deuterium content of breath following oral ingestion to determine body water

The ability to measure total body water accurately, non-invasively and rapidly with results that are immediately available would represent an important advance in body composition research. Flowing afterglow mass spectrometry (FA-MS) has been developed to enable immediate measurement of deuterium content in breath water from single exhalations, which when combined with oral D2O loading enables measurement of total body water. We report here its first use in normal subjects, demonstrating the dispersal kinetics of deuterium in the body by monitoring deuterium in breath water following ingestion. Ten studies were performed in six normal subjects. After obtaining baseline samples, each subject ingested 0.3 g x kg(-1) of 99.9% pure D2O. Subsequently, breath samples were obtained every 3-5 minutes until equilibration had occurred. Three distinct phases in breath deuterium content were observed: an initial immediate peak due to HDO remaining in the oral cavity, a secondary peak reflecting gastrointestinal absorption and finally equilibration with the body water. The incremental increase in breath deuterium abundance between baseline and equilibration was used to calculate the total body water. Mathematical fitting of this final equilibration phase demonstrated that the measured deuterium abundance was within 0.2% of the ideal (asymptotic) value within 2 hours in all cases. We conclude that FA-MS is a powerful new method that, when combined with oral D2O loading, enables measurement of the dispersal kinetics of HDO and the calculation of total body water within 2 hours.

Effects of ascites resolution after successful TIPS on nutrition in cirrhotic patients with refractory ascites

OBJECTIVE

Malnutrition is common in patients with decompensated cirrhosis and refractory ascites. The use of transjugular intrahepatic portosystemic stent shunt (TIPS) is effective in eliminating ascites. The purpose of this study was to investigate the effect of TIPS and resolution of refractory ascites on the nutritional status of patients with decompensated cirrhosis.

METHODS

Fourteen consecutive patients with refractory ascites and a Pugh score of 9.0+/-0.5 had a TIPS insertion. Biochemical data, resting energy expenditure (REE), total body nitrogen (TBN), body potassium (TBK), body fat (TBF), muscle force (MF), and food intake were recorded before TIPS, and at 3 and 12 months after the procedure.

RESULTS

Ten patients completed the study. Baseline values for REE, TBN, TBF, MF, and energy intake were below normal at baseline. There was a significant increase in dry weight, TBN, and REE at 3 and 12 months compared with baseline. TBF improved significantly at 12 months. There was a trend toward an increase in energy intake (p = 0.072). There was no change in protein intake, TBK, MF, and Pugh score.

CONCLUSION

In cirrhotic patients with refractory ascites, resolution of the ascites after TIPS placement resulted in improvement of several nutritional parameters, especially for body composition.

Nutrition in the era of highly active antiretroviral therapy

Despite tremendous advances in treatment, persons with human immunodeficiency virus (HIV) infection commonly experience a variety of nutritional problems, such as weight loss, fat redistribution, and obesity. We discuss basic dietary and metabolic problems as they pertain to persons with HIV infection and provide practical suggestions for their management. In all persons, changes in weight are caused by disruptions of energy balance, which can be disturbed by alterations in energy intake (effective ingestion of calories), energy expenditure (use of calories), or both. Factors that contribute to the disturbance of energy balance are discussed in the context of HIV infection. Management of weight loss and weight gain may then be directed at the affected components of energy balance. This information is intended to raise health care providers' attention to nutrition in their patients, including monitoring of weight, dietary issues, and relevant symptoms, and to encourage liaisons with experienced dietitians and exercise trainers.

Bioelectrical impedance analysis is a useful bedside technique to assess malnutrition in cirrhotic patients with and without ascites

Protein-calorie malnutrition is associated with poor prognosis in chronic liver disease, but reliable assessment is hampered by changes in body water. We prospectively evaluated the effect of fluid retention on bioelectrical impedance analysis (BIA) as a simple method for the estimation of body cell mass (BCM(BIA)) in 41 patients with cirrhosis (n = 20 with ascites; n = 21 without ascites) using total body potassium counting (BCM(TBP)) as a reference method. Arm muscle area and creatinine-derived lean body mass were compared with total body potassium data. In patients total body potassium was 24.4% lower than in controls and this loss was more severe in patients with ascites (-34.1%; P<.01). BCM(BIA) and BCM(TBP) were closely correlated in controls (r(2) =.87, P<.0001), patients without ascites (r(2) =.94, P <.0001) and patients with ascites (r(2) =.56, P<.0001). Removal of 6.2 +/- 3 L of ascites had only minor effects on BCM(BIA) (deviation of -0.18 kg/L ascites). Limits of agreement between both methods were wider in patients with ascites than in patients without (6.2 vs. 4.2 kg). In patients without ascites arm muscle area (r(2) =.64; P<.001) and lean body mass (r(2) =.55; P<.001) correlated significantly with total body potassium, but not in patients with ascites. For assessment of protein malnutrition in patients with cirrhosis, body cell mass determination by use of BIA offers a considerable advantage over other widely available but less accurate methods like anthropometry or the creatinine approach. Despite some limitations in patients with ascites, BIA is a reliable bedside tool for the determination of body cell mass in cirrhotic patients with and without ascites.

Impact of nutritional status on outcomes after liver transplantation

BACKGROUND

Poor preoperative nutritional status has been reported to be associated with adverse outcomes after liver transplantation. Published data are, however, conflicting, with methods of preoperative nutritional assessment and postoperative outcomes varying between studies.

METHODS

We prospectively studied the predictive value of preoperative nutritional status for adverse outcomes after liver transplantation. Assessment of preoperative nutritional status included: body cell mass determination, subjective global assessment, anthropometry, handgrip dynamometry, biochemical and amino acid profile, Child's score, and dual-energy x-ray absorptiometry. Death, intensive care unit (ICU) length of stay > or =4 days, hospital length of stay > or =15 days, blood usage > or =36 U of blood products, infection, rejection, and global resource utilization (an index of cost) greater than the median were considered poor outcomes.

RESULTS

Fifty-three patients were studied. Longer ICU stay was associated with lower handgrip strength (P<0.01) and lower aromatic amino acid levels (P<0.01). Longer total hospital stay and the development of infections were associated with lower branched chain amino acid levels (P<0.01 and <0.001, respectively). Acute cellular rejection was associated with lower total body fat (P<0.001) and higher triglyceride levels (P<0.02). Neither death nor higher global resource utilization was associated with any preoperative nutritional parameter.

CONCLUSIONS

Lower preoperative handgrip strength and branched chain amino acid levels are associated with longer ICU stays and increased likelihood of posttransplant infections. In our program, in which nutritional support was provided to potential recipients exhibiting malnourishment, none of the measured nutritional parameters were associated with mortality or greater global resource utilization.

Altered intestinal transport of amino acids in cirrhotic rats: the effect of insulin-like growth factor-I

The intestine is an important target organ for insulin-like growth factor-I (IGF-I), an anabolic hormone synthesized in the liver upon growth hormone (GH) stimulation. Levels of IGF-I are reduced in cirrhosis, and altered GH/IGF-I axis may contribute to malnutrition in cirrhotic patients. Our aim was to study Na(+)-dependent jejunal transport of amino acids (L-leucine, L-proline, L-glutamic acid, and L-cysteine) in cirrhotic rats and to analyze the effect of IGF-I on this function. IGF-I or saline was administered for 2 wk to rats with CCl(4)-induced cirrhosis and saline was administered to healthy control rats. Transport of amino acids was assessed in brush-border membrane vesicles (BBMV) using (14)C- or (35)S-labeled amino acids, and the kinetic constants V(max) and K(t) were determined. Na(+)-independent uptake of L-leucine, L-proline, L-glutamic acid, and L-cysteine by BBMV was similar in all groups. Na(+)-dependent uptake of all four amino acids was significantly diminished in cirrhotic rats compared with both controls and IGF-I-treated cirrhotic rats. The latter two groups exhibited similar V(max) and K(t), whereas untreated cirrhotic rats had reduced V(max) and increased K(t) compared with normal controls and IGF-I-treated cirrhotic animals. In conclusion, the transport of all four tested amino acids by BBMV is impaired in cirrhotic rats, and low doses of IGF-I can correct this defect.

A prospective randomized study of preoperative nutritional supplementation in patients awaiting elective orthotopic liver transplantation

BACKGROUND

Poor nutritional status is common among patients awaiting orthotopic liver transplantation and is associated with poor outcome.

METHODS

This prospective randomized controlled trial examined the effect of pretransplant nutritional supplementation on the outcome of patients undergoing liver transplantation. Of 82 consecutive patients with mid-arm muscle circumference <25th percentile, 42 received enteral supplementation, and the remainder acted as the control group. The supplemented group received a calorie-dense enteral feed taken daily (in addition to diet) until transplantation. Nutritional status was monitored by upper arm anthropometric measurements and handgrip strength. Dietary intake was calculated from 5-day food diaries.

RESULTS

Supplementation improved mid-arm circumference, mid-arm muscle circumference, and grip strength. Pretransplant nutritional status was not associated with posttransplant sepsis or major complications. Preoperative grip strength of <85% of normal values was predictive of increased incidence of posttransplant major complications. Supplementation did not affect outcome, although there were more deaths in the control group (seven deaths before and two deaths after transplant) than there were in the supplemented group (two deaths before and three deaths after transplant). There was no difference in overall survival (P = 0.075).

CONCLUSIONS

Enteral supplementation improved some parameters of nutritional status pretransplant. Dietary intake of patients in the two groups was similar at transplant. Nutritional supplementation has not increased nutritional intake, although this may reflect the importance of regular dietetic input and support, rather than suggesting that nutritional supplementation is ineffective. Supplementation had no effect on outcome of liver transplantation.

A comparison of skinfold anthropometry and dual-energy X-ray absorptiometry for the evaluation of body fat in cirrhotic patients

BACKGROUND AND AIMS

Skinfold anthropometry has been used to evaluate the nutritional status in cirrhosis. Such estimates are based on the calculations which derive from healthy subjects and may not apply to cirrhotic patients. We aimed to calculate the limits of agreement between Skinfold anthropometry (SA) and dual-energy X-ray absorptiometry (DXA) in estimating body fat in cirrhotics.

METHODS

Forty cirrhotic patients were studied by both methods. The limits of agreement were estimated by the Bland and Altman method.

RESULTS

Percentage body fat was similar when measured by DXA and SA (29.6 +/- 9.2 vs 28.9 +/- 7.5 %). Body fat mass was also similar (20.3 +/- 8.4 vs 20.3 +/- 7.7 kg). The limits of agreement between DXA and SA measurements were -7.04 (95%CI: -9.55 to -5.2) +8.56 (95%CI: +10.7 to +6.4.) in the assessment of percentage body fat and -5.32 (95%CI: -6.77 to -3.87) +5.24 (95%CI: +3.79 to +6.69) in the assessment of fat mass.

CONCLUSION

Percentage body fat can be evaluated by SA or DXA with a difference of less then 5% in the majority of cirrhotic patients without overt fluid retention. This result is important when considering the large applicability of SA.

Rapid normalization of hepatic glycogen metabolism in rats with long-term bile duct ligation after biliodigestive anastomosis

BACKGROUND/AIMS

Rats with chronic bile duct ligation have reduced hepatic glycogen stores and decreased activities of enzyme involved in glycogen metabolism. In the current studies, the reversibility of these changes following reversal of biliary obstruction by Roux-en-Y anastomosis (RY) was investigated.

METHODS

Rats were studied after bile duct ligation for 4 weeks (BDL rats), or 5 or 14 days after relief of biliary obstruction by RY. Control rats were pair-fed to treated rats, and all rats were studied in the fed state.

RESULTS

The liver glycogen content was decreased in BDL rats (198+/-167 vs. 753+/-315 mg/liver in BDL vs. control rats) and normalized within 5 days after RY. The total activities of glycogen synthase and phosphorylase were both reduced by 51% in BDL as compared to control rats. Five days after RY, the activity of glycogen synthase had increased significantly in comparison to BDL rats, whereas glycogen phosphorylase had remained unchanged. Fourteen days after RY, both enzyme activities had completely normalized. Northern blots revealed reduced hepatic mRNA levels in BDL rats, for glycogen synthase and phosphorylase. While the mRNA level for glycogen synthase normalized within 5 days after RY, the level for glycogen phosphorylase increased but did not normalize completely within 14 days after RY.

CONCLUSIONS

Hepatic glycogen stores are decreased in BDL rats but recover rapidly after relief of biliary obstruction. Reduced activity and mRNA levels of glycogen synthase suggest that impaired glycogen synthesis is the principal mechanism for decreased hepatic glycogen stores in BDL rats.

Symptoms after total gastrectomy on food intake, body composition, bone metabolism, and quality of life in gastric cancer patients--is reconstruction with a reservoir worthwhile?

Gastric cancer is worldwide one of the most common causes of cancer death. Operation is the only treatment at this time that cures some patients. The side effects of the operation are, however, considerable, and include postoperative weight loss, loss of appetite, and other metabolic and nutritional changes. The recovery is very slow and incomplete. Reconstruction with different types of pouches has been asserted to facilitate the nutritional recovery, but results from different studies are somewhat contradictory. Malnutrition, osteoporosis, osteomalacia, and impaired quality of life are often but not always described. We can, however, establish that after a total gastrectomy, gastric cancer patients are very much at risk for these complications, which are probably caused by impaired food intake and steathorrhea even when the patients are cured from their cancer disease. In order to minimize the nutritional problems, it is crucial to avoid anastomotic narrowing and bile reflux. Roux-en-Y reconstruction seems to be the method of choice. Evidence from several randomized studies now speak in favor of including some type of pouch in the reconstruction. The most commonly used pouch today is the jejunal J-pouch. How the effect is exerted is not clear. Probably both the reservoir function of the pouch and changes in intestinal transit time are important. The importance of nutritional surveillance of these patients should not be underestimated, and most of the observed differences from various reports are probably due to dissimilarity in the follow-up protocols. A patient surviving his/her cancer has a decreased risk of developing severe disturbances in bone metabolism, food intake, body composition, and quality of life if the patient is under concerned nutritional surveillance and reconstructed with a pouch.

Assessment of body composition using dual energy x-ray absorptiometry in patients with liver cirrhosis: comparison with anthropometry

OBJECTIVES

The aim of this study was to evaluate changes of body composition in cirrhotic patients. Dual energy x-ray absorptiometry (DEXA) and anthropometry were used, and the values obtained were compared.

METHODS

Mid-arm fat and muscle areas were calculated by anthropometry in 66 cirrhotic patients and 94 healthy controls. In 37 of the cirrhotic patients and 39 of the controls, fat mass, lean soft tissue mass and bone mineral contents were measured with DEXA.

RESULTS

The number of cirrhotic patients with measured values below the fifth percentile of normal controls was 21 (31.8%) by mid-arm fat area, six (9.1%) by mid-arm muscle area, 15 (40.5%) by fat mass and 0 (0%) by lean soft tissue mass. The fat mass in cirrhotic patients was less than in controls, whereas lean soft tissue mass and bone mineral content were not different. Fat depletion was severe in Child-class C patients and with severe ascites. Mid-arm fat area and fat mass showed close correlation (r = 0.85, p < 0.01), but mid-arm muscle area and lean soft tissue mass showed poor correlation (r = 0.32, p < 0.05).

CONCLUSION

Cirrhotic patients showed lower fat component, with preserved lean soft tissue mass and bone mineral content. In clinical practice, the measurement of mid-arm fat area was useful for the assessment of fat mass.

Macronutrient preference, dietary intake, and substrate oxidation among stable cirrhotic patients

Anorexia in liver disease is common; however, its association with aberrant metabolism and the type of cirrhosis has not been considered. Dietary intake, nutritional status, fasting substrate oxidation, and macronutrient preference were examined in controls (n = 18) and 65 patients with hepatocellular (n = 31) or biliary cirrhosis (n = 34). Energy intakes were lowest in hepatocellular patients (controls: 9.0 +/- 0.48 megajoules/day compared with biliary: 7.0 +/- 0.40 MJ/day, P <.05; controls compared with hepatocellular 6.5 +/- 0.39 megajoules/day, P <.01). Triceps skinfold was lower only in hepatocellular patients (controls: 109 +/- 9.2% compared with hepatocellular 79 +/- 5.6%, P <.05). The fasting rate of lipid oxidation was elevated in hepatocellular patients when compared with controls and biliary patients (controls: 40.9 +/- 15.1 mg/min compared with hepatocellular 62.8 +/- 16.8 mg/min, P <.001, and biliary : 45.5 +/- 17.0 mg/min compared with hepatocellular, P <.001). Control subjects exhibited a greater preference for the high fat, moderate carbohydrate food (controls: median 7.0 IQR 2.0 compared with biliary: median 5.0 interquartile range [IQR] 4.7, P <.01) (controls compared with hepatocellular: median 6.0 IQR 4.0, P <.01). Cirrhotic patients' spontaneous dietary intake is lower than that of controls and recommended intakes. Although macronutrient preference ratings were different within cirrhotic patient groups it remains unclear whether associated nutrient deficits are metabolically driven and dictated by primary cause.