Nutrition and the alcoholic

Nutrition in end stage liver disease

This chapter will focus on studies within the last 5 years of nutrition in end stage liver disease, but earlier studies illustrating the present state of affairs will also be mentioned. The first part will focus on descriptive epidemiological studies that help to set the scene for the intervention studies, which will be described in the second part. Each part will discuss liver cirrhosis, acute liver failure and liver transplantation separately. The aim is to provide the reader with sufficient background for the decision in clinical practice about when to see nutrition support as an important part of treatment of the patient.

Effects of alcohol on skeletal and cardiac muscle

The acute and chronic toxic effects of alcohol on skeletal and cardiac muscle are clinically important. Muscle weakness and atrophy are the main manifestations of skeletal myopathy, and arrhythmias and progressive left-ventricular dysfunction are those of cardiomyopathy. Most patients remain asymptomatic from these effects for a long time. Myocyte atrophy and death are the main pathological findings. A clear dose-related effect has been established with ethanol consumption, with gender and some specific gene polymorphisms being factors of increased susceptibility to alcohol-induced muscle damage. Pathogenic mechanisms are pleiotropic, the most relevant being disturbances in carbohydrate, protein, and energy cell turnover, signal transduction, and induction of apoptosis and gene dysregulation. Ethanol abstinence is the only effective treatment, although controlled drinking is useful in patients who do not achieve abstinence. Persistent high-dose consumption results in deterioration of muscle and heart function, with a high mortality due to arrhythmias and progression of heart failure.

Ethanol dosage regimes in studies of ethanol toxicity: influence of nutrition and surgical interventions

In this review we consider some of the practical facets of acute and chronic drug regimes. In particular, we illustrate our arguments with specific reference to alcohol and draw attention to methodological constraints that might alter biochemical or physiological processes. These includes the imposition of nutritional abnormalities and surgical procedures. These two areas are highlighted because there is evidence to show that they have marked influences on metabolic parameters, exemplified by tissue protein synthesis. In general, there is no controversy as to methods for acute studies with alcohol, although some reports have failed to investigate whether intravenous, intragastric or intraperitoneal regimes more accurately mimic the clinical situation. With regard to chronic feeding regimes, evidence is provided to support the argument that, currently, the most appropriate feeding protocol ensures that both control and treated groups receive identical amounts of nutrients albeit with differences in the calories apportioned to ethanol, which is substituted by isocaloric glucose or other carbohydrates in controls. However, there are still other methods being employed: these are subject to misinterpretation as the principle of ensuring that control and ethanol-fed rats receive identical amounts of nutrients, is ignored. In this review we also draw attention to the fact that surgical procedures, which are often employed to facilitate the measurement of body parameters (for example, implantation of cannulae), themselves alter tissue metabolism. The importance of this relates to the concept of metabolic superimposition, which implicates interacting responses when two or more stresses (i.e. surgery and drug administration) are superimposed.

Influence of nutritional status on alcoholic myopathy

BACKGROUND

Muscle weakness and structural changes in striated skeletal muscle are common in persons with chronic alcoholism.

OBJECTIVE

The objective of the study was to assess the role of malnutrition in the development of chronic alcoholic myopathy.

DESIGN

We prospectively evaluated 146 men who reported an intake >/=100 g ethanol/d for the previous 5 y and 73 well-nourished control subjects. Alcohol consumption, energy and protein nutritional status, and deltoid muscle strength were determined. Deltoid muscle tissue specimens were taken from alcoholics and from 14 control subjects for histochemical studies and morphometric measurements of the fibers.

RESULTS

Deltoid muscle strength was less in alcoholics than in control subjects (P < 0.001). Muscle strength correlated with lifetime consumption of ethanol (r = -0.56, P < 0.001), and a decrease in muscle strength was significantly greater in the presence of energy malnutrition. Using logistic regression analysis, we observed that alcoholics with muscle strength < 18 kg had the independent risk factors of an arm muscle area < 50 cm(2) (odds ratio: 5.4; 95% CI: 2.3, 12.3), consumption of > 1600 kg ethanol throughout their lives (odds ratio: 4.5; 95% CI: 2.0, 10.1), and protein malnutrition (odds ratio: 4.2; 95% CI: 1.4, 12.7). Protein malnutrition was also associated with muscle inefficiency (P < 0.001). Histologic myopathy was present in 58% of alcoholics, was related to lifetime ethanol consumption (P = 0.001), and was more severe in the presence of protein malnutrition (P = 0.01).

CONCLUSION

Malnutrition is an additional developmental factor in the functional and structural muscle damage induced by chronic ethanol consumption.

The health-related effects of alcohol use in older persons: a systematic review

Increased alcohol consumption is associated with substantial morbidity and mortality in young and middle-aged adult populations, but its effects on the health of older adults have received less attention. The objective of the study was to review published studies that assessed the effects of alcohol on falls or fall injuries, functional impairment, cognitive impairment, and all-cause mortality among older adults. MEDLINE database and bibliographies of selected citations were searched for English language studies published between 1966 and 1998 that examined the relationship between alcohol and one or more of the above outcomes. Also a study was analyzed if it included participants 60 years of age or older, or a broader age range of participants and reported results for older subgroups, or predominantly older participants as evidenced by a mean age of 65 years of age or above. Information on studies' sample sizes, exposure and outcome measures, and risk estimates were extracted, and articles were evaluated for methodologic quality using predetermined criteria. Eighty-four studies were identified that examined 91 potential exposure-outcome associations including falls or fall injuries (n = 26); functional impairment (n = 13); cognitive impairment (n = 32); and all-cause mortality (n = 20). The percentage of studies demonstrating harm, no association, or benefit by outcome included falls (15% vs. 81% vs. 4%); functional disability (38% vs. 46% vs. 16%); cognitive impairment (31% vs. 66% vs. 3%); and all-cause mortality (15% vs. 65% vs. 20%). Studies (n = 84) inconsistently adhered to methodologic standards. Although 90% provided eligibility criteria; 61% cited participation rates; and 73% described the methods used to measure alcohol exposure; only 44% adjusted for potentially important confounding factors; and 26% distinguished former drinkers from nondrinkers. Of the cohort studies (n = 47), 30% assessed for change in participants' exposure status over time, and 17% determined whether losses to follow-up varied by exposure status. The magnitude of risk posed by alcohol use for falls or fall injuries, functional disability, cognitive impairment, and all-cause mortality among older adults remains uncertain. Prospective studies are needed to better define the health-related effects of alcohol use in older populations.

Osteopenia assessed by body composition analysis is related to malnutrition in alcoholic patients

Osteopenia is frequent among alcoholics. Its pathogenesis seems to be multifactorial, including ethanol intake, hormonal changes, liver cirrhosis, and malnutrition. Our objective is to determine the relative role of malnutrition on bone loss. One hundred and eighty-one male alcoholic patients, drinkers of more than 80 g ethanol/day, were included, recording data on the intensity of alcoholism, liver cirrhosis, nutritional assessment based on feeding habits, body mass index (BMI), midarm anthropometrics, subjective nutritional assessment, lean and fat mass by dual energy X-ray absorptiometry (DEXA), serum proteins and insulin growth factor Type I (IGF-I), calcitropic hormones, parathyroid hormone (PTH), osteocalcin 25OHD3, and bone mass assessed by DEXA, which was also performed in 43 healthy controls. Alcoholics showed decreased serum osteocalcin, PTH, 25OHD3, IGF-I, and bone mass. Alcoholics were frequently malnourished with decreased BMI, lean, and fat mass. The loss of bone mass was not related to the alteration of calcitropic hormones, to the intensity of alcoholism, or to the existence of liver cirrhosis, but to malnutrition. For a similar BMI, bone loss was more intense in alcoholics than in controls, especially in those with irregular feeding habits. Although cross-sectional ones, our data suggest that alcoholic osteopenia may be interpreted as a form of nutritional osteoporosis, notwithstanding the influence of other factors.

Nutritional assessment in alcoholic patients. Its relationship with alcoholic intake, feeding habits, organic complications and social problems

To establish their ability to predict malnutrition, irregular feeding, alcoholic intake, derangement of social and familial links and organic complications (liver cirrhosis) were assessed in 181 hospitalized male alcoholic. BMI was under 18.5 kg/m(2) in 8.9%, between 18.5-20 kg/m(2) in 8.9%, 20-25 kg/m(2) in 42%, 25-30 kg/m(2) in 32.2% and over 30 kg/m(2) in 8.2% of patients. Malnutrition was related to the intensity of ethanol intake, development of social or familial problems, irregularity of feeding habits and cirrhosis with ascites. Irregularity of feeding habits was also related to heavy drinking and to social or familial derangement. By logistic regression analysis, the only variables which independently predict malnutrition were irregular feeding habits and liver cirrhosis with ascites. In a second step, irregular feeding was dependent on social or familial troubles and daily intake of ethanol. So, malnutrition related to alcoholism seems multifactorial in its pathogenesis.

A comparison of the nutritional status and food security of drug-using and non-drug-using Hispanic women in Hartford, Connecticut

This study compared food insecurity, nutritional status (as measured through anthropometry and dietary intake), and food preparation patterns of low-income Puerto Rican female out-of-treatment drug users with that of low-income Puerto Rican women who reported no drug use. A convenience sample of 41 drug users was compared with 41 age-matched non-drug-users from inner-city Hartford, Connecticut. A culturally appropriate food frequency questionnaire was administered and anthropometric measurements were taken. The findings suggest a high degree of poverty among all study participants, but in particular among drug users. Drug users were more likely than the controls to be food insecure (P < 0.05) and to be exposed to increasingly severe food sufficiency problems. The daily frequency of consumption of vegetables was lower (P = 0.03) for drug users than non-drug-users. Conversely, the frequency of consumption for sweets/desserts was significantly higher for drug users than the controls (P = 0.0001). Drug users, who were classified as food insecure were less likely to consume vegetables (P = 0.004) and fish (P = 0.03) than were controls who were food insecure. When comparing drug users with controls, the former group reported consuming fewer meals during a usual week than the latter group (P < 0.0001). Drug users were more likely to fry foods (P = 0.02) while the controls were more likely to bake (P = 0.005), boil (P = 0.02), and steam (P = 0.002) foods. All anthropometric measurements, except for height, were significantly lower for drug users. The results show that drug users generally maintain poorer nutritional status than non-drug-users. Nutrition interventions as part of drug treatment are needed.

Protein-energy status and 15N-glycine kinetic study of child a cirrhotic patients fed low- to high-protein energy diets

In five male cirrhotic patients (Child A) and in four age- and sex-matched healthy control subjects, whole-body protein turnover was measured using a single oral dose of 15N-glycine as a tracer and urinary ammonia as end product. Subjects were studied in the fasting and feeding state, with different levels of protein and energy intake. The patients were underweight and presented lower plasma transthyretin and retinol-binding protein levels. When compared with controls, the kinetic studies showed patients to be hypometabolic in the fasting (D0) state and with the control diet [D1 = (0.85 g of protein/ 154 kJ) x kg-1.day-1]. However, when corrected by body weight, the kinetic differences between groups disappeared, whereas the N-retention in the feeding state showed better results for the patients due mainly to their efficient breakdown decrease. When fed high-level protein or energy diets [D1 = (0.9 g protein/195 kJ) and D3 = (1.56 g protein/158 kJ) x kg-1.day-1], the patients showed D0 = D1 = D2 < D3 for N-flux and (D0 = D1) < D3 (D2 is intermediary) for protein synthesis. Thus, the present data suggest that the remaining mass of the undernourished mild cirrhotic patients has fairly good protein synthesis activity and also that protein, rather than energy intake, would be the limiting factor for increasing their whole-body protein synthesis.

Chronic alcoholism: an important condition in the dentist-patient relationship

OBJECTIVES

This paper aims to give the dental practitioner an insight into the impact of chronic alcoholism on sufferers.

METHODS

A review of the psychiatric and dental literature covering the aetiology, prevalence and complications is presented.

CONCLUSIONS

Chronic alcoholism has a number of serious medical and social problems which may affect the provision of dental treatment. It is important for the dental practitioner to be aware of the impact of this condition on patients as he or she may be in an ideal position to stop the alcoholic before a medical consultation has been sought.

Effect of red wine consumption on rat liver peroxidation

To evaluate the role of wine polyphenols and that of alcohol on lipid peroxidation indexes and membrane composition in the liver, 40 Sprague-Dawley rats were fed for 28 days with a commercial AIN-76 diet to which was added one of four different beverages: red wine, alcohol solution, dealcoholated wine, or water. The beverage provided 26% of the caloric intake. Peroxidation indexes and antioxidative enzymes were determined: no significant differences were detected in catalase and glutathione peroxidase whereas superoxide dismutase was significantly lower in the wine-treated animals (220.3 +/- 15.4 vs. 342.2 +/- 43.0 U/mg protein of controls). The following significant differences in hepatic variables were observed: increased alpha-tocopherol concentration in the alcohol group (0.17 +/- 0.02 vs. 0.11 +/- 0.01 microgram/mg protein of controls); increased concentration of cytochrome P450 in the rats given wine (0.75 +/- 0.06 vs. 0.51 +/- 0.08 nmol/mg protein of the alcohol group); increased concentration of cytochrome b5 in wine and dealcoholated wine treatment groups (0.30 +/- 0.01 vs. 0.23 +/- 0.02 nmol/mg protein of controls). The liver membrane fatty acid composition of the wine and dealcoholated wine groups was similar and showed an increase in the saturated fatty acid percentage and a decrease in the polyunsaturated one. The data presented indicate that the main action of polyphenols seems to be an induction of cytochrome activity and that the modality of red wine administration adopted combined with an adequate diet does not provoke any apparent physiological effect on the animals.

A 7-year experience of severe acetaminophen-induced hepatotoxicity (1987-1993)

BACKGROUND & AIMS

Five hundred sixty patients admitted between January 1, 1987, and December 31, 1993, with severe acetaminophen-induced hepatotoxicity were studied. The aim of this study was to identify why severe acetaminophen-induced hepatotoxicity still occurs and to determine how known risk factors and advances in management have affected the pattern of illness and outcome.

METHODS

This was a retrospective study of the etiologic factors and the clinical course of all acetaminophen-related admissions.

RESULTS

The number of admissions increased from 58 in 1987 to 123 in 1993. During the corresponding period, overall survival improved from just < 50% to 78%. The percentage of admissions treated with N-acetylcysteine increased from 40% in 1987 to 83% in 1993. The frequency with which grade III or IV encephalopathy developed decreased from 62% in 1987 to 40% in 1993, and the percentage of these patients who developed cerebral edema decreased from 61% to 45% during the same period. There was an increase in both the number of patients transplanted and the survival of those managed medically.

CONCLUSIONS

Severe acetaminophen-induced hepatotoxicity remains a serious condition, but the increasing use of N-acetylcysteine, advances in medical management, and the increasing availability of transplantation have resulted in a significant improvement in survival rates.

High fat diet and liver damage induced by biliary obstruction in the rat

There is a great body of evidence linking a high fat diet with the formation of gallstones. However, the effect of fat per se on obstructive liver damage (not involving gallstone formation) has not been assessed. The aim of this work was to study the effect of a high fat diet on liver damage induced by bile duct ligation in rats. Male 21-day-old Wistar rats were divided into two groups: group 1 received standard Purina chow diet 5001 containing 4.5% fat, group 2 received Purina chow diet 5001 enriched with 33% pork fat. Animals were allowed food and water ad libitum for 5 weeks. Obstructive jaundice was induced by double ligation and division of the common bile duct. The animals were sacrificed 1 week after biliary obstruction. Control animals were sham operated. Serum bilirubins and alkaline phosphatase, gamma-glutamyl transpeptidase and glutamic pyruvic transminase enzyme activities increased by biliary obstruction. Glycogen content decreased in the bile duct-ligated rats. These effects were more important in the group fed a 33% fat diet. Our results show that a high animal fat diet increases liver damage in experimental biliary obstruction in rats. Owing to our experimental design (bile duct ligation), the effect of a high fat diet cannot be attributed to an increase in the formation of gallstones but a direct effect must be considered. The mechanism by which fat augmented liver damage can be associated with an increase of total bile content and its toxicity.

[Role of hepatocellular insufficiency and kidney failure on nutritional management]

Chronic liver disease as well as chronic renal failure are responsible for abnormal nutrient metabolism and high rates of undernutrition. Although surgery is frequently required in such patients, the perioperative nutritional management has not yet been extensively studied in these conditions. During chronic liver disease, preoperative nutritional status and postoperative outcome are correlated. However, nutritional status can only be considered as one out of several factors of the prognosis, including the grade of liver insufficiency and the type of surgical procedure. Thus, it is difficult to evaluate the real influence of undernutrition on postoperative outcome. Similarly, the usefulness of preoperative nutrition is not definitely demonstrated in this condition. The nutritional requirements of patients with liver cirrhosis are estimated to be protein 1g and 30-35 kcal.kg-1.d-1. The duration of nutritional supplementation before surgery may not exceed 10 days. Postoperative parenteral nutrition seems to be well tolerated during chronic liver disease. Although some data in the literature suggest that it may be of interest after liver transplantation, the efficacy of postoperative parenteral nutrition needs to be proven in larger series. In chronically uraemic patients, the effects of undernutrition on postoperative morbidity and mortality have been poorly studied. Infectious complications after renal transplantation are favoured by several factors, including immunosuppressive therapy and malnutrition. The efficacy as well as the tolerance of perioperative nutritional support in patients with chronic renal failure are poorly known. In haemodialysis patients, candidates for renal graft, the nutritional status is usually well preserved when the recommended nutritional needs are provided: proteins 1.2-1.4 g and 35-40 kcal.kg-1.d-1.

Chronic alcoholic myopathy and nutritional status

To investigate the prevalence of alcoholic myopathy and its relationship to the nutritional status, we performed a muscle biopsy on the vastum lateralis of 60 consecutive hospitalized alcoholic patients using a Tru-Cut needle, processing it for light microscope and ultrastructural analysis. The nutritional status was assessed by anthropometric measurements such as midarm circumference, triceps skinfold and midarm muscle area, and serum albumin. The hallmark of chronic alcoholic myopathy, fiber muscle atrophy, was present in 33% of the patients, necrosis scarcely being observed (1.5%). Ultrastructural alterations as lipid and glycogen accumulation or mitochondrial and myofibrillar alterations were nonspecific and observed in nearly all the cases where atrophy was present. Malnutrition was frequent in our patients: 39% and 34% showed a triceps skinfold and a midarm muscle area, respectively, under the fifth populational percentile. Patients with muscle fiber atrophy or ultrastructural changes showed a worse nutritional status, not only regarding muscle protein (assessed by midarm muscle area or creatininuria and explained by fiber atrophy), but also regarding fat stores assessed by triceps skinfold. Toxic effect of ethanol and malnutrition may act synergistically leading to chronic alcoholic myopathy.

Nutritional assessment and adequacy of dietary intake in hospitalized patients with alcoholic liver cirrhosis

Nutritional assessment and adequacy of spontaneous dietary intake was evaluated in thirty-seven clinically stable hospitalized patients with alcoholic liver cirrhosis. About two-thirds of the patients had ascites or oedema, or both, and, therefore, body weight could not be used for assessment of nutritional status. Lean body mass (LBM; measured by three consecutive 24 h creatinine excretions) was 62 (range 40-95)% of reference values, mid-arm-muscle area (MAMA) was 70 (range 43-115)% and triceps skinfold (TSF) was 45 (range 20-113)% of reference values (all median values). In patients without ascites or oedema, or both, there was a rectilinear correlation between body weight and LBM and between body weight and MAMA (r 0.93 and 0.85 respectively). In patients with ascites or oedema, or both, the correlation between body weight and LBM was poor as could be expected. We suggest that LBM is a useful measure of nutritional status when body weight is unreliable because of ascites or oedema, or both. Energy balance for the group was calculated from energy intake recorded by a 24 h dietary recall and energy expenditure calculated by the factorial method. Median intake was 102 (range 34-176)% of expenditure. N loss was calculated from the average of three 24 h urea excretions. Protein intake was calculated from the 24 h dietary recall. The N balance was positive in the patients as a group (median intake was 120 (range 26-183)% of output). The most malnourished patients tended to have the most positive N balance which was due to a significantly lower N excretion. The protein requirement for N balance was 0.83 (SE 0.05) g/kg per d and only at an intake above 1.20 g/kg per d were all patients in positive N balance. The median intakes of thiamin, folacin, vitamin D, vitamin E, Mg, and Zn were judged to be insufficient. It is concluded that impaired nutritional status is common among patients with liver cirrhosis, even in a stable clinical condition. It is suggested that nutritional status in these patients is evaluated by dietary recalls, in combination with measurement of body weight in patients without ascites or oedema, or both, or in combination with determination of LBM by three 24 h creatinine excretions in patients with ascites or oedema, or both. Criteria for selection of patients that might benefit from nutritional therapy are discussed.

A comparative study of serum selenium and vitamin E levels in a population of male risk drinkers and abstainers. A population-based matched-pair study

Depressed selenium and Vitamin E levels may contribute to hepatic injury through lipid peroxidation. To study the effect of moderate alcohol drinking (32.4 +/- 23.6 g ethanol/d) on serum selenium and serum vitamin E concentrations, we conducted a matched-pair study of 73 healthy, well-nourished risk drinkers and healthy controls with little or no alcohol consumption. Among risk drinkers, serum selenium was significantly lowered (1.49 vs 1.67 mumol/L; p < 0.001) compared with controls. Difference in alpha-tocopherol concentrations did not, however, reach statistical significance (22.8 vs 24.9 mumol/L; p = 0.06). Nutritional and life-style factors differed very little between the two groups. We conclude that even moderate alcohol consumption lowers selenium status. Selenium may thus represent a link joining the hepatotoxic and nutritional backgrounds of alcoholic liver disease.

Oral magnesium supplementation improves metabolic variables and muscle strength in alcoholics

Magnesium deficiency is common among chronic alcoholics, but the knowledge of oral magnesium supplementation to this group is limited. We, therefore, randomized 49 chronic alcoholics, moderate to heavy drinkers for at least 10 years to receive oral magnesium or placebo treatment for 6 weeks according to a double-blind protocol. Effects on metabolic variables and muscle strength were analyzed. Significant reduction of aspartate-aminotransferase (ASAT), alanine-aminotransferase (ALAT) and gamma-glutamyl-transpeptidase (GGT) were seen after magnesium, whereas no change was observed with placebo. Bilirubin decreased in both groups. Serum Na, Ca, and P increased significantly during magnesium therapy compared with no statistically significant change in the placebo group. Serum K and Mg increased slightly after magnesium supplementation and decreased in the placebo group, resulting in a significant difference between the two groups at the end of the study. Muscle strength increased significantly during magnesium treatment, contrasting to no change with placebo. Blood pressure, heart rate, hematological variables, serum lipids (cholesterol, HDL, TG), glucose tolerance, and creatinine were unchanged in the two groups after treatment. Alcohol consumption was similar before and during the trial and does not explain the differences between the two groups The results shows that short-term oral magnesium therapy may improve liver cell function, electrolyte status, and muscle strength in chronic alcoholics.

Cirrhosis as an independent risk factor for colonic adenomas

This study aimed to determine the relation between cirrhosis and colorectal adenomatous polyps after adjustment for alcoholism and other confounding variables. Four groups of patients aged 40 years or above were studied. Group I included 100 consecutive outpatients with irritable bowel syndrome, group II 100 consecutive alcoholic inpatients without cirrhosis, group III 100 consecutive inpatients with alcoholic cirrhosis, and group IV included 36 consecutive inpatients with non-alcoholic cirrhosis. All patients underwent colonoscopy. The prevalence of adenomatous polyps was 13% in group I, 26% in group II, 58% in group III, and 22% in group IV (p less than 0.001). The prevalence of adenomatous polyps was greater in patients with cirrhosis than in those patients without (48.5% v 19.5%). This difference remained significant after successive adjustment for alcoholism, sex, age, smoking, and serum cholesterol. The prevalence of adenomatous polyps was greater in alcoholic patients than in non-alcoholic patients (42% v 15.4%) (p less than 0.001). This difference remained significant after successive adjustment for cirrhosis, sex, age, smoking, and serum cholesterol. These results suggest that cirrhosis is an independent risk factor for colorectal adenomatous polyps and confirm that alcoholism increases this risk.

Alcohol, liver, and nutrition

Until two decades ago, dietary deficiencies were considered to be the major reason why alcoholics developed liver disease. As the overall nutrition of the population improved, more emphasis was placed on secondary malnutrition. Direct hepatotoxic effects of ethanol were also established, some of which were linked to redox changes produced by reduced nicotinamide adenine dinucleotide (NADH) generated via the alcohol dehydrogenase (ADH) pathway. It was also determined that ethanol can be oxidized by a microsomal ethanol oxidizing system (MEOS) involving cytochrome P-450: the newly discovered ethanol-inducible cytochrome P-450 (P-450IIE1) contributes to ethanol metabolism, tolerance, energy wastage (with associated weight loss), and the selective hepatic perivenular toxicity of various xenobiotics. P-450 induction also explains depletion (and enhanced toxicity) of nutritional factors such as vitamin A. Even at the early fatty-liver stage, alcoholics commonly have a very low hepatic concentration of vitamin A. Ethanol administration in animals was found to depress hepatic levels of vitamin A, even when administered with diets containing large amounts of the vitamin, reflecting, in part, accelerated microsomal degradation through newly discovered microsomal pathways of retinol metabolism, inducible by either ethanol or drug administration. The hepatic depletion of vitamin A was strikingly exacerbated when ethanol and other drugs were given together, mimicking a common clinical occurrence. Hepatic retinoid depletion was found to be associated with lysosomal lesions and decreased detoxification of chemical carcinogens. To alleviate these adverse effects, as well as to correct problems of night blindness and sexual inadequacies, the alcoholic patient should be provided with vitamin A supplementation. Such therapy, however, is complicated by the fact that in excessive amounts vitamin A is hepatotoxic, an effect exacerbated by long-term ethanol consumption. This results in striking morphologic and functional alterations of the mitochondria with leakage of mitochondrial enzymes, hepatic necrosis, and fibrosis. Thus, treatment with vitamin A and other nutritional factors (such as proteins) is beneficial but must take into account a narrowed therapeutic window in alcoholics who have increased needs for such nutrients, but also display an enhanced susceptibility to their adverse effects. Massive doses of choline also exerted some toxic effects and failed to prevent the development of alcoholic cirrhosis. Acetaldehyde (the metabolite produced from ethanol by either ADH or MEOS) impairs hepatic oxygen utilization and forms protein adducts, resulting in antibody production, enzyme inactivation, and decreased DNA repair. It also enhances pyridoxine and perhaps folate degradation and stimulates collagen production by the vitamin A storing cells (lipocytes) and myofibroblasts.(ABSTRACT TRUNCATED AT 400 WORDS)

The effect of chronic alcohol intake on prognosis and outcome in paracetamol overdose

1. In a retrospective study, we stratified 79 patients with paracetamol hepatotoxicity into two groups according to weekly alcohol consumption below (n = 49) or above (n = 30) Royal College of Physicians' guidelines of 21 units week-1 for males and 14 for females. 2. Survival was lower (33%) and serum creatinine on admission higher (median 207 mumol) in patients whose alcohol consumption was above recommended guidelines than in those whose drank less than this (65.9% and 138 mumol, P less than 0.01 and P = 0.027, respectively). An arterial blood pH less than 7.30 on admission was also more common in those patients with a higher alcohol consumption (30% v 12.2%, P = 0.05). 3. In all patients whose alcohol consumption exceeded the guidelines, paracetamol overdose was fatal if associated with a serum creatinine greater than 300 mumol in conjunction with a prothrombin time over 100 s and grade 3 or 4 encephalopathy or a peak prothrombin time over 180 s. 4. Chronic alcohol intake above suggested limits is an adverse prognostic feature in cases of severe paracetamol overdose. This effect is partly related to increased nephrotoxicity.

Follow-up of a cohort of alcoholic patients through 12 months of comprehensive biobehavioral treatment

One hundred and eleven socially stable alcoholic patients were subjected to a comprehensive diagnostic and treatment protocol based on a biobehavioral model of alcoholism. Physical pathology, malnutrition, and toxicity were prevalent throughout the sample. After a period of inpatient care, subjects were treated for a period of 12 months with a combination of medical, nutritional, behavioral, and psychological support and care. At the end of the study period, 91 subjects (81.9%) remained in treatment contact. Sixty seven subjects (60.4%) were abstinent and physically stable at the 12-month date. Elevations of three scales of the MMPI were significantly predictive of treatment outcome.

Chronic ethanol consumption depresses hypothalamic-pituitary-adrenal function in aged rats

In separate experiments, nine (n = 20) and fifteen (n = 12) month old rats were treated with either 6% ethanol or 12% sucrose (to balance caloric intake) in the drinking water to examine the effect of chronic ethanol consumption on the hypothalamic-pituitary-adrenal axis of aged rats. Rats were maintained on these treatment regimens for thirty days and were killed by decapitation. Blood was collected and plasma concentrations of adrenocorticotropin (ACTH) and corticosterone were determined by radioimmunoassay. Adrenal glands were cleaned, quartered and used to test in vitro responsiveness to ACTH. Anterior pituitary glands from all 15 month old rats and one half of the nine month old rats were collected, frozen and extracted for measurement of tissue ACTH concentration. The remaining anterior pituitary glands from the nine month old rats were challenged with corticotropin releasing hormone (CRH) to test in vitro responsiveness. In nine month old rats, chronic ethanol consumption decreased plasma ACTH and corticosterone (P less than 0.05). Pituitary ACTH concentrations were unchanged in treated nine month old rats, but the amount of pituitary ACTH released in response to CRH was decreased (P less than 0.05) in rats consuming ethanol. In vitro responsiveness of the adrenal gland to ACTH in nine month old rats consuming ethanol was unchanged (P greater than 0.05). Plasma ACTH and corticosterone concentrations were also decreased in 15 month old rats chronically consuming ethanol (P less than 0.05). No differences were noted in responsiveness of the adrenal gland or in the amount of pituitary ACTH due to ethanol consumption in 15 month old rats (P greater than 0.05). The results of these experiments indicate that chronic ethanol consumption decreases hypothalamic-pituitary-adrenal function in aged rats.

Energy equivalents of CO2 and their importance in assessing energy expenditure when using tracer techniques

Carbon dioxide production in free living animals and humans can be measured using tracer techniques, but the prediction of energy expenditure also requires an estimate of the energy equivalents of CO2 (energy expended/CO2 produced; EeqCO2). This work is concerned with assessing the variation in EeqCO2 with the use of dietary information, indirect calorimetry, and theoretical concepts. The EeqCO2 for diets (EeqCO2 diet) ingested by 63 individuals living in a Cambridgeshire village, UK, was found to vary by less than 10%. The EeqCO2 diet for different populations varied by greater than 10% and for artificial enteral feeds by approximately 20%. Alcohol increases this variability because it has a particularly high EeqCO2. Variation in the nitrogenous end products of metabolism may also have a substantial effect on the EeqCO2 for a subject (EeqCO2 body), especially when a large proportion of energy expenditure is derived from protein oxidation, as in strict carnivores. Nutrient/energy imbalances such as those associated with growth, hypercaloric feeding, or starvation may also have major effects on EeqCO2 body. It is concluded that the calculation of energy expenditure from CO2 production should not employ a universal value for EeqCO2 body. The value should take into account the physiological and clinical state under investigation. Practical recommendations are suggested.

Body composition in detoxified alcoholics

Body composition was evaluated in healthy detoxified alcoholics (aged 20-39) and lifestyle controls, with the expectation that prolonged, excessive consumption of alcohol may bring about nutritional or toxicologic alterations in the relationship between body fat and lean body mass. Body fat was assessed by measurements of skin-fold thickness and by means of bioelectric impedance methodology. No noteworthy differences were observed between alcoholics and controls with regard to the relationship between lean body mass and body fat or in the relationship between extracellular and intracellular water. It would appear that 15-20 years of heavy alcohol consumption does not necessarily alter body composition in healthy, young alcoholics.

[Malignant hyperthermia during alcohol withdrawal]

Heat shock is the consequence of malignant hyperthermia triggered by general anaesthesia, the use of neuroleptic drugs, or strenuous muscular exercise. Chronic alcoholism could be a contributing factor by facilitating the triggering of malignant hyperthermia. We describe two cases of malignant hyperthermia which occurred during the summer in undernourished chronic alcoholics showing withdrawal syndrome during their stay in hospital. General anaesthesia and neuroleptics were excluded as the origin of their malignant hyperthermia, and we looked for new mechanisms to explain the heat shock, other than shivering associated with the withdrawal syndrome or the high temperature of the season. These two patients were considered deficient in thiamine on admission, their plasma pyruvic acid level being sharply increased (185 mumol/l and 304 mumol/l respectively; normal range: 45.6-91.2 mumol/l). This deficiency can lead to disregulation of thermal centres. Other metabolic disorders, frequently observed in alcoholics, could facilitate heat release during withdrawal syndrome shivering. The risk of heat shock during abrupt alcohol withdrawal should not be underestimated.

Decreased hepatic selenium content in alcoholic cirrhosis

Selenium deficiency has been implicated as contributing to hepatic injury in alcoholics. The mechanism by which this occurs is most likely lipoperoxidation secondary to decreased activity of the selenoenzyme glutathione peroxidase. To further assess this relationship, we measured selenium content in autopsy livers in 12 patients with alcoholic cirrhosis compared to 13 patients matched for age and sex dying from other causes, mostly with cardiopulmonary diseases. The mean (+/- SEM) hepatic selenium content in cirrhosis was 0.731 +/- 0.077 microgram/g dry weight versus 1.309 +/- 0.166 microgram/g in controls (P less than 0.005; Student's t test). Clinical and biochemical indices of significant hepatic dysfunction, including encephalopathy, ascites, and elevations of serum bilirubin or prothrombin time, were only present in the cirrhotic group. A significant inverse correlation between hepatic selenium content and the prothrombin time was noted (r = -0.50; P less than 0.02). No significant relationships between hepatic selenium and the abnormalities of bilirubin, albumin, or aspartate aminotransferase were found. We conclude that significantly decreased hepatic selenium stores are present in patients with severe alcoholic cirrhosis compared to controls. The magnitude of that selenium deficit does correlate with some indices of hepatic function, specifically the prothrombin time. These data lend further support to a true selenium deficiency state in alcoholic cirrhosis. It is highly possible that selenium deficiency represents an important link, synergistically joining the nutritional and hepatotoxic backgrounds of alcoholic liver injury and cirrhosis.

A prospective multicenter study of insulin and glucagon infusion therapy in acute alcoholic hepatitis

A randomized, single-blind controlled multicenter study of insulin and glucagon infusion was carried out in 66 patients with acute alcoholic hepatitis. Thirty-three patients were treated with insulin 10 U and glucagon 1 mg in 500 ml 5% glucose in water via a peripheral vein for 2-6 h three times every day for 3 weeks. Patients in the control group received 5% glucose in an identical fashion. Fourteen control patients and five treated patients died from liver failure during the study (P less than 0.02). Clinical features of liver disease on entry into the study were similar in the two groups, but the total serum bilirubin, aspartate aminotransferase, gamma-glutamyltranspeptidase activities and prothrombin time significantly improved in the treated patients (P less than 0.05). Insulin and glucagon infusion appears to be a promising treatment of acute alcoholic hepatitis.

Early biochemical and histological changes in rats exposed to a single injection of thioacetamide

Liver injury was induced by one subcutaneous administration of thioacetamide (200 mg/kg b.wt.) and studied 24 and 48 hrs later. Levels of aspartate aminotransferase (ASAT) and alanine aminotransferase (ALAT) increased after 24 and 48 hrs. The lysosomal enzymes beta-hexosaminidase (beta-NAG) and beta-glucuronidase (beta-GLU) increased significantly after 24 hrs, while the level of beta-GLU returned to normal after 48 hrs, but the activity of beta-NAG remained significantly high even after 48 hrs. Histopathological examination showed necrotic hepatocytes around the central vein with infiltration of macrophages, neutrophils and eosinophils. The plasma zinc level decreased after 24 hrs and returned to normal after 48 hrs. Liver zinc content increased simultaneously at 24 hrs, returning to normal after 48 hrs. No alterations of plasma copper were observed after 24 and 48 hrs. Copper content of the liver increased significantly after 24 and 48 hrs. The present study thus shows that one dose of thioacetamide results in profound liver injury and supplementation of zinc prior to and simultaneously with thioacetamide normalized plasma zinc, increased liver zinc content and reduced the increase of beta-NAG, but did not influence the histological changes.

Zinc and ethanol: dietary interrelationships in pregnant rats

Pregnant rats were fed three different liquid diets with ethanol providing 33.3, 35.6 and 50.8% of the total calories. The 35.6 and 50.8% ethanol diets, containing egg white as a source of protein, were zinc deficient and were fed to two groups of rats without zinc supplementation. At each level of ethanol, one additional group was supplemented with a moderate level of zinc and another group with a high level of zinc. The 33.3% ethanol diet contained casein as a source of protein and had a high level of zinc. Each rat in the ethanol group was yoked with another rat fed a diet in which the ethanol was replaced by an isocaloric amount of carbohydrate. Records were kept of food consumed, weight gained or lost, number of pups delivered, total weight of litter, and weights of each pup. Maternal and neonatal tissues were taken for zinc and copper analyses. The rats fed ethanol diets were found to ingest the same amount of ethanol-derived calories per day regardless of diet or concentration of ethanol. On the higher level of ethanol (50.8%), the rats, therefore, ingested fewer total calories and lost weight. No pups were delivered from this group of dams. Their respective pair-fed groups, although restricted in weight gain, delivered live pups at all levels of zinc. The pups from dams fed zinc-deficient diets had lower total body zinc levels and lower liver zinc levels. Sufficient dietary zinc improved the condition of the pregnant rats and their progeny, but there were no indications that higher levels of dietary zinc resulted in further improvement.(ABSTRACT TRUNCATED AT 250 WORDS)

Lipid abnormalities in plasma and red cell membranes of chronic alcoholics

The fatty acid composition of plasma and red cell membranes was determined in alcoholics without liver dysfunction upon admission for withdrawal therapy and after a 4-week period of abstinence, and in normal subjects. Fatty acid analysis of plasma by capillary gas chromatography showed a higher proportion of saturated fatty acids in alcoholics on admission than in normal subjects. Other major differences in plasma fatty acids in alcoholics were the reduction of linoleic acid and the increase in palmitic acid. Similar abnormalities were measured in red cell membranes of alcoholics. Although there were less polyunsaturated fatty acids in red cells of alcoholics, the degree of hydrogen peroxide or phenylhydrazine-induced lipid peroxidation was the same as in controls. Membrane tolerance to ethanol was attributed to adaptive membrane alterations (increase of saturated fatty acids in membranes). However, the here reported changes in plasma and red cell lipids suggest that alterations in red cell membrane lipids reflect abnormalities in plasma lipids due to equilibrium exchanges rather than signify adaptive changes of the red cells to ethanol.