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

Micronutrients in Liver Disease: Roles, Risk Factors for Deficiency, and Recommendations for Supplementation

Micronutrients are essential components of the diet and are required to maintain fundamental bodily functions. Liver disease has a profound effect on nutrient intake, metabolism of nutrients, and nutrition status, often resulting in some degree of malnutrition, including micronutrient deficiency. Vitamin and mineral deficiencies can impair metabolic processes at the cellular and biochemical level even before clinical and physical alterations are seen. It is essential that micronutrient status is evaluated as part of a comprehensive nutrition assessment for all patients with chronic or advanced liver disease. Early intervention to correct suspected or confirmed deficiencies may minimize symptoms and improve clinical outcomes and quality of life. In this narrative review, different types of liver disease and associated micronutrient abnormalities are outlined, and methods of micronutrient assessment and supplementation are discussed.

Impact of nutrition and obesity on chronic liver disease

Undernutrition and obesity are at opposite ends of a spectrum that has an enormous impact on all aspects of liver diseases. The myriad effects of the opposing ends of the nutrition spectrum have led to a wealth of research aimed at elucidating the exact mechanisms of how they cause liver damage. In this article, the role of the liver in nutrient and energy metabolism is discussed, as well as the known and possible effects of specific nutrient deficiencies and obesity.

High prevalence of vitamin A deficiency and vitamin D deficiency in patients evaluated for liver transplantation

Deficiencies in vitamins A, D, and E have been linked to night blindness, bone health, and post-liver transplant reperfusion injury. The aim of this study was to determine the prevalence and predictive factors of fat-soluble vitamin deficiencies in liver transplant candidates. We reviewed the medical records of liver transplant candidates at our center from January 2008 to September 2011. The etiology of cirrhosis, Model for End-Stage Liver Disease score, Child-Pugh class, body mass index (BMI), and vitamin A, vitamin E, and vitamin 25-OH-D levels were recorded. Patients were excluded for incomplete laboratory data, short gut syndrome, celiac disease, pancreatic insufficiency, or prior liver transplantation. Sixty-three patients were included. The most common etiologies of liver disease were alcohol (n = 23), hepatitis C virus (n = 19), and nonalcoholic steatohepatitis (n = 5). Vitamin A and D deficiencies were noted in 69.8% and 81.0%, respectively. Only 3.2% of the patients were vitamin E-deficient. There were no documented cases of night blindness. Twenty-five of the 55 patients with bone density measurements had osteopenia, and 10 had osteoporosis. Four patients had vertebral fractures. There was 1 case of posttransplant reperfusion injury in a patient with vitamin E deficiency. In a multivariate analysis, there were no statistically significant predictors for vitamin D deficiency. The Child-Pugh class [odds ratio (OR) = 6.84, 95% confidence interval (CI) = 1.52-30.86, P = 0.01], elevated total bilirubin level (OR = 44.23, 95% CI = 5.02-389.41, P < 0.001), and elevated BMI (OR = 1.17, 95% CI = 1.00-1.36, P = 0.045) were found to be predictors of vitamin A deficiency. In conclusion, the majority of liver disease patients evaluated for liver transplantation at our center had vitamin A and D deficiencies. The presence or absence of cholestatic liver disease did not predict deficiencies, whereas Child-Pugh class, bilirubin level, and elevated BMI predicted vitamin A deficiency.

Oxidative-inflammatory damage in cirrhosis: effect of vitamin E and a fermented papaya preparation

BACKGROUND AND AIM

Oxidative DNA damage occurs as an early event in hepatitis C virus (HCV) infection and is an indication of the potential for carcinogenesis. The aim of this study was to test a novel antioxidant/immunomodulator in patients with HCV-related cirrhosis.

METHODS

The study group consisted of 50 patients with HCV-related cirrhosis with transaminase values less than twofold increased (alanine aminotransferase [ALT] < 80 IU/L). Patients underwent a standardized food-vitamin composition assessment and were assessed for dietary intake, nutritional status and iron level. Patients were randomly allocated into two groups and then given either alpha-tocopherol 900 IU/day or 9 g/day of a fermented papaya preparation (FPP, Immun-Age, Osato Research Institute, Gifu, Japan) at bedtime for 6 months. Ten healthy subjects served as controls. Patients were checked monthly for: routine tests, redox status (reduced glutathione, glutathione peroxidase, oxidized glutathione, malondialdehyde), plasma alpha-tocopherol, 8-hydroxy-deoxy-guanidine (8-OHdG) level in circulating leukocyte DNA and serum levels of cytokines.

RESULTS

Patients with cirrhosis showed a significant imbalance of redox status (low antioxidants/high oxidative stress markers) (P < 0.005 vs controls). Neither treatment regimen affected transaminases as a whole. However, vitamin E supplementation almost normalized ALT only in the limited vitamin-E-deficient subgroup. A significant improvement of redox status was obtained by both regimens. However, only FPP significantly decreased 8-OHdG and the improvement of cytokine balance with FPP was significantly better than with vitamin E treatment (P < 0.05).

CONCLUSIONS

Although the present data seem to suggest a potential supportive role of antioxidants/immunomodulators as FPP in HCV patients, more studies are needed to substantiate their effect on the natural history of the disease.

High preoperative recipient plasma 7beta-hydroxycholesterol is associated with initial poor graft function after liver transplantation

Oxidative stress is implicated in the pathogenesis of hepatic ischemia-reperfusion injury, a major determinant of initial poor graft function (IPGF) after orthotopic liver transplantation (OLT). We prospectively investigated the association between the recipient plasma preoperative oxidative stress and the occurrence of IPGF after deceased-donor OLT and indirectly studied the source-hepatic or extra-hepatic-of systemic oxidative stress in vivo in cirrhosis. We used a recently developed specific and sensitive mass spectrometry assay to measure 7beta-hydroxycholesterol and 7-ketocholesterol (oxysterols), markers of oxidative stress, in biological matrices. At univariate analysis, preoperative recipient 7beta-hydroxycholesterol plasma concentration was significantly higher in transplants with subsequent IPGF (n = 9) compared with those with initial good graft function (IGGF; n = 23) [mean +/- SD: 30.63 +/- 26.42 and 11.57 +/- 15.76 ng/mL, respectively] (P = 0.017). In a logistic regression model, which included also the Model for End-Stage Liver Disease (MELD) score, 7beta-hydroxycholesterol plasma concentration was an independent predictor of IPGF with an odds ratio of 1.17 (95% CI, 1.02-1.33, P = 0.028). Patients with cirrhosis (n = 32) had increased oxysterol plasma levels compared with healthy controls (n = 49); livers with cirrhosis (n = 21), however, had oxysterol content comparable with normal livers obtained from organ donors (n = 19). Oxysterols persisted elevated in plasma 1 month after OLT (n = 23). In conclusion, cirrhosis presents upregulated systemic oxidative stress likely of extrahepatic source that is associated with graft failure after OLT.

High-dose vitamin E supplementation does not diminish ribavirin-associated haemolysis in hepatitis C treatment with combination standard alpha-interferon and ribavirin

BACKGROUND

Ribavirin is associated with haemolytic anaemia. Antioxidants have been reported to decrease severity of this anaemia.

AIM

To determine effect of vitamin E supplementation on ribavirin-associated haemolysis in chronic hepatitis C treated with standard alpha-interferon and ribavirin.

METHODS

Fifty-one naive chronic hepatitis C patients were randomized to receive either alpha-interferon/ribavirin therapy (control) or therapy plus vitamin E 800 IU b.d. with 24-week follow-up. Alanine aminotransferase ALT, haemoglobin and reticulocyte percentage were monitored. Symptoms and health-related quality of life were also monitored at each visit.

RESULTS

Forty-seven subjects were treated (27 vitamin E /20 controls). Thirteen withdrew because of adverse effects or non-compliance. Groups were similar in demographics, genotype and baseline lab indices. Comparison with baseline, treatment and follow-up values showed a significant haemoglobin and ALT reduction in both groups. There was no significant difference in haemoglobin and reticulocyte percentage between groups. Sustained viral response was not significantly different between vitamin E (11/18) and control (6/16) groups. Three patients required ribavirin dose-reduction in the vitamin E group compared with two controls. Health-related quality of life during and end-of-treatment was not different between groups.

CONCLUSIONS

Vitamin E supplementation alone during standard alpha-interferon and ribavirin therapy does not appear to diminish ribavirin-associated haemolysis.

Vitamin E supplementation increases polyunsaturated fatty acids of RBC membrane in HCV-infected patients

OBJECTIVE

We investigated the effects of vitamin E supplementation on the fatty acid composition of red blood cell membrane phospholipids and on the clinical observations in patients with hepatitis C virus.

METHOD

Eight patients and control subjects were administered 500 mg/d of d-alpha-tocopherol for 12 wk. The alpha-tocopherol and fatty acid composition of phospholipids in red blood cells were analyzed before, at 4, 8, and 12 wk, and after 4 wk of washout of vitamin E administration.

RESULTS

The alpha-tocopherol concentration in red blood cells increased 2.37-fold of the basal level during vitamin E supplementation. Serum alanine aminotransferase levels increased in five of eight patients with vitamin E supplementation. The arachidonic acid level, docosahexaenoic acid level, and ratio of polyunsaturated to saturated fatty acid in red blood cell membrane phospholipids, which were significantly lower in the patients than in the control subjects, were elevated at 8 and 12 wk after vitamin E supplementation. The improvement in fatty acid composition was observed particularly in the patients who responded to the vitamin E therapy.

CONCLUSIONS

Vitamin E therapy for the prevention of disease progression in patients with hepatitis C virus may be effective.

Habitual food intake and polyunsaturated fatty acid deficiency in liver cirrhosis

OBJECTIVE

We compared the habitual food intake and plasma fatty acid composition in cirrhotic patients living in two different regions in Japan, Okayama and Toyama, and evaluated the effects of dietary polyunsaturated fatty acid and alpha-tocopherol intake on serum alanine aminotransferase (ALT) activity.

METHOD

A quantitative food-frequency questionnaire method was used.

RESULTS

The significantly higher intake of fish in the patients living in Toyama resulted in higher plasma levels of docosahexaenoic acid and lower levels of arachidonic acid. Serum ALT activity correlated negatively with plasma arachidonic acid (r = -0.456, P < 0.05) and alpha-tocopherol (r = -0.505, P < 0.05) levels. Dietary intakes of vitamin E and polyunsaturated fatty acids (mg/g) correlated negatively with serum ALT (r = -0.377, P < 0.05). Dietary intake of linoleic acid and the ratio of polyunsaturated to saturated fatty acid in dietary fat correlated significantly with serum ALT (r = 0.604, P < 0.01, and r = 0.622, P < 0.01, respectively). The amount of vegetable intake correlated with intake of vitamin E and polyunsaturated fatty acid (r = 0.527, P < 0.02).

CONCLUSIONS

These findings suggest that habitual food intake affects the plasma fatty acid profile and that elevated serum ALT may be related to arachidonic acid deficiency and vulnerability to lipid peroxidation in cirrhotic patients with hepatitis B and C viruses.

Nutritional and metabolic issues in cirrhosis and liver transplantation

In the last year some relevant papers on nutrition and metabolism in chronic liver disease and transplantation have been published. Studies investigating the reliability of predicting energy expenditure in cirrhosis, and some relevant contributions to the understanding of metabolic consequences of liver transplantation, deserve particular mention. These include the first direct evidence that liver transplantation corrects the insulin resistance present in cirrhosis, as well as studies on the role of genetic polymorphism of the vitamin D receptor gene in bone loss after transplantation. Other papers have dealt with body composition, polyunsaturated fatty acid and antioxidant status in cirrhosis. However, relevant contributions in the field of nutritional support in cirrhosis are surprisingly lacking.

Interferon/antioxidant combination therapy for chronic hepatitis C--a controlled pilot trial

The effects of two forms of antioxidative co-therapy were analyzed in 24 interferon-alpha (IFN)-naive patients with chronic hepatitis C who were randomized to either receive IFN monotherapy (3 x 4.5 million units IFN-alpha 2a per week), (group A), or IFN and N-acetylcysteine (N-acetylcysteine (NAC) 1.800 mg/day) plus sodium selenite (400 microg/day) supplementation (group B), or treatment as in group B plus vitamin E (544 IU/day) (group C), over 24 weeks. Changes in histology, normalization of ALT, reduction of viral RNA, serum levels of glutathione, selenium, vitamin E, erythrocyte glutathione peroxidase, trolox equivalent antioxidative capacity (TEAC), thiobarbituric acid reactive substances (TBARS) and protein carbonyl groups were measured. Low baseline TEAC and elevated TBARS indicated increased oxidative stress before therapy, which was not affected by antioxidant supplementation. At the end of treatment complete responses were found in 3/8, 2/8 and 6/8 patients in groups A, B and C, respectively, but liver histology had not significantly improved. Vitamin E treated patients had a 2.4 greater chance (95% CI: 1.05-5.5) of obtaining a complete response and had significantly greater reduction in viral load (P = 0.028) than patients without vitamin E. Relapses, i.e. re-appearance of detectable hepatitis C virus (HCV) RNA and/or re-elevation of ALT-activity occurred in 7 out of the 11 responders within 6 months after termination of therapy (group A: 2/3, group B: 1/2 and group C: 4/6). Thus, no overall beneficial effect of antioxidant/IFN therapy was detected. However, the apparent trend towards a more favorable outcome with vitamin E supplementation warrants to further study this substance as an adjuvant to IFN therapy in chronic hepatitis C.

Nutritional issues in cirrhosis and liver transplantation

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