Nutritional support in liver failure

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.

Nutrition support for individuals with liver failure

The prevalence of liver diseases is increasing in the United States, particularly as a result of the recent hepatitis C epidemic. In the past, patients who developed fulminant hepatic failure or cirrhosis owing to a chronic liver disease were likely to expire. During the last 15-20 years, liver transplantation has given these patients a chance at survival. Progressive nutrition deficiencies and muscle wasting are universal problems in these patients. Left untreated, the progressive wasting of liver disease leads to infection and an increased risk of death owing to infection both before and after transplantation. Aggressive nutritional support is essential to optimize the care of these patients and to enable them to obtain and survive a liver transplant and gain access to a new life following a successful liver engraftment.

Experience of parenteral nutrition for nutritional rescue in children with severe liver disease following failure of enteral nutrition

Nutritional support is often necessary in chronic liver disease in childhood, and when enteral nutrition is insufficient, parenteral nutrition (PN) can be envisaged as a last resort. Pediatric experience is still limited in this indication. Seven children with severe liver disease received PN for a mean duration of 105 d, with additional enteral nutrition. Clinical tolerance was assessed and anthropometric and biological data were compared at the beginning and at the end of the study by the paired non-parametric test of Wilcoxon. Weight change, expressed as weight-for-age or weight-for-height Z-scores, increased. Conjugated bilirubin increased significantly. This retrospective study suggests that PN is a well-tolerated method for maintaining nutritional status in pediatric chronic liver disease when enteral nutrition has failed.

Dietary nucleotides have cytoprotective properties in rat liver damaged by thioacetamide

Liver cirrhosis has been induced with thioacetamide administered via different routes in rats and other species. The oral intake of thioacetamide causes nodular liver cirrhosis in rats characterized by extensive fibrosis occupying most of the hepatic parenchyma. To characterize the cytological features of cirrhosis induced by thioacetamide, and the degree of recovery obtained with dietary nucleotides, we made a morphometric study of the hepatocytes in rats administered 300 mg/l of thioacetamide for 4 months, and in rats receiving the same hepatotoxic treatment but allowed a 2-weeks recovery period on a nucleotide-free diet or a 250 mg/100 g nucleotide-supplemented diet. Thioacetamide caused to cell damage and affected the ultrastructure of hepatocytes leading to a decrease in cytoplasmic area together with increased nuclear and nucleolar size. Dietary supplementation with nucleotides favoured recovery, restoring the cytoplasmic (TN=491.7+/-9.6 vs TAA=305.1+/-3.7), nuclear (73.6+/-2.8 vs 97.4+/-2.9), and nucleolar area of damaged hepatocytes (5.6+/-0.3 vs 14.0+/-0.9). The injury from thioacetamide intake increased liver collagen, but dietary nucleotides prevented hepatic deposition of this protein. This study supports the hypothesis that dietary supplementation with nucleotides is decisive in ensuring hepatocyte recovery after thioacetamide-induced liver damage, and that dietary nucleotides have antifibrotic properties.

A questionnaire to assess the generic and disease-specific health outcomes of patients with chronic hepatitis C

A 69-item questionnaire measuring generic functioning and well-being and disease-specific health outcomes was developed and tested using the pre-treatment data from patients with chronic hepatitis C (CHC) participating in two randomized trials of interferon alpha-2b (n = 157). The questionnaire included all eight scales from the SF-36 and measures of nine other generic and disease-specific health concepts. Psychometric tests confirmed the assumptions underlying the construction and scoring of all generic and disease-specific scales. Cross-sectional tests of 'known groups' validity showed that CHC patients scored worse on the generic scales than patients with other chronic conditions and worse than a healthy general population. The generic and disease-specific scale scores were lower in the presence of physical findings of CHC, as hypothesized, but only the physical functioning and bodily pain scales were linked to cirrhosis or extreme alanine aminotransferase (ALT) ratios. This instrument will be useful in studies of health outcome among patients with CHC, a condition whose health burden appears to have been underestimated in studies to date.

Influence of dietary nucleotides on liver structural recovery and hepatocyte binuclearity in cirrhosis induced by thioacetamide

Intake of thioacetamide in drinking water causes liver cirrhosis in rats, which exhibit many changes similar to human disease. Nucleotides play an important part in major cellular functions, and recent studies suggest that dietary nucleotides may be considered 'semi-essential' nutrients in situations when an inadequate dietary supply may affect the growth of tissues with a rapid turnover rate. The aim of this study was to assess the effect of dietary nucleotides on lesions in thioacetamide-cirrhotic rats, and to calculate the proportion of mono and binucleated hepatocytes in different experimental groups. Rats were given cirrhosis by oral intake of thioacetamide in the drinking water (300 mg/l) for four months. One group was treated with a standard nucleotide free diet, and another group was treated with the same diet supplemented with 250 mg of nucleotides per 100 g of diet for one and two weeks. A striking reduction (mean (SEM)) in the proportion of binucleated cells was seen in thioacetamide-cirrhotic rats (4.8 (1.3) v 21.4 (1.0)), showing a change in the mitotic mechanism in focal lesions. Cirrhotic rats that consumed a semipurified diet supplemented with nucleotides during two weeks showed considerable histological regeneration of the injured liver. These animals had significantly higher proportion of binucleated cells than did animals at the beginning of the recovery period (8.2 (1.2) v 4.8 (1.3)). In the second week of recovery, both types of diet (F = 5.54, p < 0.05) and the previous administration of thioacetamide (F = 142.82, p < 0.001) had significant effects on the percentage of binucleated hepatocytes.

Influence of administration of long-chain polyunsaturated fatty acids on process of histological recovery in liver cirrhosis produced by oral intake of thioacetamide

Patients with liver cirrhosis frequently show some degree of protein-energy malnutrition and obviously require nutritional support. In this study, the treatment of rats consisted of the ad libitum oral intake of a 300 mg/liter thioacetamide solution, used as drinking water for four months. Thioacetamide treatment produced a severe alteration in the plasma fatty acid profile with significant decreases of these, which mimicked changes described in human cirrhosis. This hepatotoxic agent causes nodular cirrhosis, with loss of the normal architecture of the liver and disruption of the vascular pattern. The goal of the study was to evaluate the influence of n-3 and n-6 series long-chain polyunsaturated fatty acid dietary supplementation in experimental animals and to assess the effects of those dietary components on structural recovery in the liver. Significant increases of saturated and monounsaturated fatty acids as well as n-6 polyunsaturated fatty acids were seen only in the animals given the n-6 polyunsaturated fatty acid supplemented diet. However, only rats given the standard diet exhibited some degree of histological regeneration.