Effect of late evening snack with rice ball on energy metabolism in liver cirrhosis

Meal timing and its role in obesity and associated diseases

Meal timing emerges as a crucial factor influencing metabolic health that can be explained by the tight interaction between the endogenous circadian clock and metabolic homeostasis. Mistimed food intake, such as delayed or nighttime consumption, leads to desynchronization of the internal circadian clock and is associated with an increased risk for obesity and associated metabolic disturbances such as type 2 diabetes and cardiovascular diseases. Conversely, meal timing aligned with cellular rhythms can optimize the performance of tissues and organs. In this review, we provide an overview of the metabolic effects of meal timing and discuss the underlying mechanisms. Additionally, we explore factors influencing meal timing, including internal determinants such as chronotype and genetics, as well as external influences like social factors, cultural aspects, and work schedules. This review could contribute to defining meal-timing-based recommendations for public health initiatives and developing guidelines for effective lifestyle modifications targeting the prevention and treatment of obesity and associated metabolic diseases. Furthermore, it sheds light on crucial factors that must be considered in the design of future food timing intervention trials.

Unlocking the Power of Late-Evening Snacks: Practical Ready-to-Prescribe Chart Menu for Patients with Cirrhosis

The efficacy of the late-evening snack (LES) has been extensively studied due to the impact of the longest intermeal duration occurring at night in patients with cirrhosis. While actual clinical guidelines on nutrition in chronic liver disease recommend an LES, no specific nutritional compositions have been reported by the European Association for the Study of the Liver (EASL) and the European Society for Clinical Nutrition and Metabolism (ESPEN). Late-evening snacks vary greatly among studies, including natural foods and/or nutritional supplements, yet oral supplements still need to fully meet the LES's nutritional composition. In addition, many hepatologists need to gain experience in nutritional approaches and have access to registered dieticians who can help them manage patients with liver disease. Therefore, this review study aims to summarise evidence regarding using LESs and the mechanisms behind long starvation in patients with cirrhosis. It also provides a practical nutritional guide with several LES options based on common natural foods tailored to special patients' nutritional requirements and geographical backgrounds. In preventing accelerated starvation and related protein malnutrition and sarcopenia in patients with cirrhosis, the nutritional composition of LESs is essential. The proper and straightforward application of the LES's rational nutrition is an advantage to cirrhotic patients and should be carried out by healthcare professionals to enhance the overall liver function and nutritional status of patients with cirrhosis.

From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients

Liver transplantation (LT) is a complex surgical procedure requiring thorough pre- and post-operative planning and care. The nutritional status of the patient before, during, and after LT is crucial to surgical success and long-term prognosis. This review aims to assess nutritional status assessment and management before, during, and after LT, with a focus on patients who have undergone bariatric surgery. We performed a comprehensive topic search on MEDLINE, Ovid, In-Process, Cochrane Library, EMBASE, and PubMed up to March 2023. It identifies key factors influencing the nutritional status of liver transplant patients, such as pre-existing malnutrition, the type and severity of liver disease, comorbidities, and immunosuppressive medications. The review highlights the importance of pre-operative nutritional assessment and intervention, close nutritional status monitoring, individualised nutrition care plans, and ongoing nutritional support and monitoring after LT. The review concludes by examining the effect of bariatric surgery on the nutritional status of liver transplant recipients. The review offers valuable insights into the challenges and opportunities for optimising nutritional status before, during, and after LT.

Effects of Branched-Chain Amino Acids on Parameters Evaluating Sarcopenia in Liver Cirrhosis: Systematic Review and Meta-Analysis

INTRODUCTION

Sarcopenia is a major element of malnutrition in liver cirrhosis (LC) and is present in 30-70% of this population, being associated with a poor overall prognosis due to related complications such as hepatic encephalopathy, ascites, and portal hypertension. This systematic review and meta-analysis aimed to evaluate the effects of branched-chain amino acids (BCAA) supplementation on several parameters used to assess sarcopenia in LC.

MATERIALS AND METHODS

A comprehensive systematic electronic search was performed in PubMed, EMBASE, Scopus, Cochrane Library, and ClinicalTrials.gov databases using predefined keywords. We included full articles that satisfied the inclusion and exclusion criteria. Quality assessment of included studies was conducted using Cochrane Collaboration's tool and NHLBI quality assessment tools for interventional and observational studies, respectively. The principal summary outcome was the mean difference (MD) in the evaluated parameters. We performed a pre- and post-intervention analysis and comparison between two intervention groups (BCAA vs. controls) of the evaluated parameters when applicable.

RESULTS

A total of 12 studies involving 1,225 subjects were included in our qualitative synthesis and five in our quantitative synthesis. At baseline vs. post-intervention assessment, subjects receiving BCAA supplementation were found to have a significant improvement in skeletal muscle index (SMI) (-0.347 [95% CI -0.628-0.067; p-value 0.015]) and mid-arm muscle circumference (MAMC) (-1.273 [95% CI (-2.251-0.294; p-value 0.011]). However, no improvements were reported in handgrip (-0.616 [95% CI -2.818-1.586; p-value 0.584]) and triceps subcutaneous fat (1.10 [95% CI -0.814-3.014; p-value 0.263]).

CONCLUSION

Following BCAA supplementation, several parameters used to evaluate sarcopenia in LC patients were found to be improved, including SMI and MAMC. Nevertheless, no improvements were seen in handgrip and triceps subcutaneous fat. Results should be interpreted with caution due to the limited methodological quality of the included studies.

Relationship Between Sleep-Wake Disturbance and Risk of Malnutrition in Hospitalized Patients With Cirrhosis

Both sleep-wake disturbance and malnutrition are common in cirrhosis and might be associated with similar adverse outcomes, such as impaired health-related quality of life, hepatic encephalopathy, and sarcopenia, but there is no study investigating the relationship between these two. We aimed to explore the relationship between sleep-wake disturbance [estimated by the Pittsburgh Sleep Quality Index (PSQI)] and malnutrition risk [estimated by the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT)]. About 150 patients with cirrhosis were prospectively recruited. The nutritional risk is classified as low (0 points), moderate (1 point), and high (2-7 points) according to the RFH-NPT score. A global PSQI >5 indicated poor sleepers. Furthermore, multivariate linear regression analyses were performed to determine the relationship between sleep-wake disturbance and malnutrition. The median PSQI was seven, and RFH-NPT was two in the entire cohort, with 60.67 and 56.67% rated as poor sleep quality and high malnutrition risk, respectively. Patients with cirrhosis with poor sleep quality had significantly higher RFH-NPT score (3 vs. 1, P = 0.007). Our multivariate analyses indicated that male patients (β = 0.279, P < 0.001), ascites (β = 0.210, P = 0.016), and PSQI (β = 0.262, P = 0.001) were independent predictors of malnutrition. In addition, the differences regarding PSQI score were more significant in male patients, as well as those >65 years or with Child-Turcotte-Pugh class A/B (CTP-A/B) or the median model for end-stage liver disease (MELD) <15. Taken together, the sleep-wake disturbance is strongly correlated with high malnutrition risk in patients with cirrhosis. Given sleep-wake disturbance is remediable, it is tempting to incorporate therapies to reverse poor sleep quality for improving nutritional status in patients with cirrhosis.

Nutritional Evaluation and Treatment of the Cirrhotic Patient

Malnutrition and sarcopenia that lead to functional deterioration, frailty, and increased risk for complications and mortality are common in cirrhosis. Sarcopenic obesity, which is associated with worse outcomes than either condition alone, may be overlooked. Lifestyle intervention aiming for moderate weight reduction can be offered to obese compensated cirrhotic patients, with diet consisting of reduced caloric intake, achieved by reduction of carbohydrate and fat intake, while maintaining high protein intake. Dietary and moderate exercise interventions in patients with cirrhosis are beneficial. Cirrhotic patients with malnutrition should have nutritional counseling, and all patients should be encouraged to avoid a sedentary lifestyle.

Effect of non-alcoholic beer, diet and exercise on endothelial function, nutrition and quality of life in patients with cirrhosis

BACKGROUND

The implementation of nutritional strategies targeting several variables at once could benefit patients with cirrhosis. Non-alcoholic beer has different compounds that exert antioxidant, anti-inflammatory and nutritional properties.

AIM

To evaluate the effect of diet + exercise and non-alcoholic beer on nutritional status, endothelial function and quality of life in patients with cirrhosis.

METHODS

In this randomized open clinical trial, patients with cirrhosis were randomized into two groups: The intervention (non-alcoholic beer + diet + exercise) and control (water + diet + exercise) group. Treatment consisted of 330 mL non-alcoholic beer/day or the same amount of water, plus an individualized dietary plan and an exercise program with a pedometer-based bracelet to reach at least 5000 steps/d and > 2500 above the baseline during 8 wk. Endothelial function (flow-mediated dilation, plethysmography), biochemical and nutritional variables and quality of life (CLDQ) were evaluated.

RESULTS

Forty-three patients were included in the study, 21 in the control group and 22 in the intervention group. The mean age was 53.5 ± 7.8 years, 60% were women, the median MELD score was 8 (7-10) and most patients were Child-Pugh A (88%). Adherence to the interventions was > 90% in both groups, there were no adverse events and all biochemical parameters remained stable in both groups. Endothelial function improved in both groups. All measured nutritional parameters improved in the intervention group, compared to only 2 in the control group and quality of life improved in both groups; however, more domains improved in the intervention group.

CONCLUSION

The intervention consisting of non-alcoholic beer, diet and exercise seems to be safe and well tolerated in patients with cirrhosis, and shows improvement in nutritional status, endothelial function, and quality of life. These results need to be further confirmed.

Switching from branched-chain amino acid granules to branched-chain amino acid-enriched nutrient improves the branched-chain amino acid-to-tyrosine ratio in patients with cirrhosis with hypoalbuminemia: a prospective study

OBJECTIVE

The present study aimed to elucidate the effect of switching from branched-chain amino acid granules to branched-chain amino acid-enriched nutrient in patients with cirrhosis with hypoalbuminemia.

METHODS

Twenty-six patients with cirrhosis with hypoalbuminemia despite treatment with branched-chain amino acid granules containing 12 g of branched-chain amino acid were enrolled in the prospective study. The branched-chain amino acid-enriched nutrient and control groups were composed of 16 and 10 patients, respectively. The patients in branched-chain amino acid-enriched nutrient group switched to branched-chain amino acid-enriched nutrient mixture containing 12.2 g of branched-chain amino acid and 410 kcal with a half of it consumed as a late evening snack, and the patients in the control group continued branched-chain amino acid granules. Laboratory data related to nutrition parameter were assessed at baseline, 3 months after baseline, and at 6 months after baseline.

RESULTS

Two patients were withdrawn; hence, nine and 15 patients in the branched-chain amino acid granules and branched-chain amino acid-enriched nutrient groups, respectively, were subjected to full analysis. Serum albumin levels and total lymphocyte counts in both groups did not change in the study period. The branched-chain amino acid-to-tyrosine ratio in the branched-chain amino acid-enriched nutrient group significantly increased from baseline to 6 months after baseline (P = 0.030), whereas that in the control group did not increase.

CONCLUSION

Switching from branched-chain amino acid granules to branched-chain amino acid-enriched nutrients improves branched-chain amino acid-to-tyrosine ratio in patients with cirrhosis with hypoalbuminemia.

Timing of Food Intake: Identifying Contributing Factors to Design Effective Interventions

Observations that mistimed food intake may have adverse metabolic health effects have generated interest in personalizing food timing recommendations in interventional studies and public health strategies for the purpose of disease prevention and improving overall health. Small, controlled, and short-termed intervention studies suggest that food timing may be modified as it is presumed to be primarily regulated by choice. Identifying and evaluating social and biological factors that explain variability in food timing may determine whether changes in food timing in uncontrolled, free-living environments are sustainable in the long term, and may facilitate design of successful food timing-based interventions. Based on a comprehensive literature search, we summarize 1) cultural and environmental factors; 2) behavioral and personal preference factors; and 3) physiological factors that influence the time when people consume foods. Furthermore, we 1) highlight vulnerable populations who have been identified in experimental and epidemiological studies to be at risk of mistimed food intake and thus necessitating intervention; 2) identify currently used food timing assessment tools and their limitations; and 3) indicate other important considerations for the design of food timing interventions based on successful strategies that address timing of other lifestyle behaviors. Conclusions drawn from this overview may help design practical food timing interventions, develop feasible public health programs, and establish guidelines for effective lifestyle recommendations for prevention and treatment of adverse health outcomes attributed to mistimed food intake.

Interventions to improve sarcopenia in cirrhosis: A systematic review

BACKGROUND

Sarcopenia, i.e., muscle loss is now a well-recognized complication of cirrhosis and in cases of non-alcoholic fatty liver disease can contribute to accelerate liver fibrosis leading to cirrhosis. Hence, it is imperative to study interventions which targets to improve sarcopenia in cirrhosis.

AIM

To examine the relationship between interventions such nutritional supplementation, exercise, combined life style intervention, testosterone replacement and trans jugular intrahepatic portosystemic shunt (TIPS) to improve muscle mass in cirrhosis.

METHODS

We search PubMed, EMBASE and Cochrane between June-August 2018, without a limiting period and the types of articles (RCTs, clinical trial, comparative study) in adult patients with sarcopenia and cirrhosis. The primary outcome of interest was improvement in muscle mass, strength and physical function interventions mentioned above. In the screening process, 154 full text articles were included in the review and 129 studies were excluded.

RESULTS

We identified 24 studies that met review inclusion criteria. The studies were diverse in terms of the design, setting, interventions, and outcome measurements. We performed only qualitative synthesis of evidence due to heterogeneity amongst studies. Risk of bias was medium in most of the included studies and low quality of evidence showed improvement in the muscle mass, strength and physical function following aerobic exercise. 60% of the included studies on the nutritional intervention, 100% of the studies on testosterone replacement in hypogonadal men and trans-jugular portosystemic shunt were proved to be effective in improving sarcopenia in cirrhosis.

CONCLUSION

Although the quality of evidence is low, the findings of our systematic review suggest improvement in the sarcopenia in cirrhosis with exercise, nutritional interventions, hormonal and TIPS interventions. High quality randomized controlled trials needed to further strengthen these findings.

Late evening snacks with branched-chain amino acids improve the Fischer ratio with patients liver cirrhosis at fasting in the next morning

BACKGROUND & AIMS

A late evening snack (LES) is recommended as a nutritional therapy for liver cirrhosis to minimize early starvation. In patients with liver cirrhosis, the maintenance of the branched-chain amino acid (BCAA) levels is important during muscle synthesis at night. Therefore, we investigated the effects of a LES with BCAAs on the Fischer ratio in patients with liver cirrhosis.

METHODS

This study included 10 outpatients with liver cirrhosis who did not consume a LES. Regarding the patient characteristics, the mean age was 73.1 ± 8.9 years, the male:female ratio was 5:5, and the mean body mass index was 23.3 ± 2.4 kg/m². The etiology was hepatitis C virus in eight patients and alcoholism in two patients. Amino acid levels were measured in all 10 patients at four time points: before LES (control) and 1 month after the administration of each BCAA. The administration levels included 1) LES: BCAA-enriched enteral nutrition (BCAA-EN) containing BCAAs 6.1 g as a LES; 2) GP-no LES: BCAA-enriched granule product (BCAA-GP) containing 4 g BCAAs per pack, two packs per day, and BCAA-EN until dinner containing BCAAs in total 14.1 g per day; and 3) GP-LES: BCAA-GP, two packs per day, and BCAA-EN as a LES containing BCAAs in total 14.1 g per day. The Friedman nonparametric test with a post-hoc Dunn's multiple comparison was used for statistical analyses.

RESULTS

There were no significant changes in body weight and serum albumin levels between the three types of BCAA administration. Valine significantly increased following LES and GP-LES, isoleucine significantly increased following GP-LES, and tyrosine significantly decreased following LES and GP-LES compared with those in the control. There was no significant difference in the leucine and phenylalanine levels among the groups. The Fischer ratio in the LES (2.2 ± 0.8) and GP-LES (2.3 ± 0.8) groups were significantly higher than that in the control (1.8 ± 0.6), but there was no significant difference compared with the Fischer ratio in the GP-no LES (1.8 ± 0.7) group. Furthermore, the Fischer ratio was significantly higher in the GP-LES group than in the GP-no LES group.

CONCLUSION

These results suggested that it is not only the amount of BCAAs, but also LES with BCAAs, which is needed to improve the Fischer ratio at fasting.

Indirect calorimetry as point of care testing

Determining energy requirement is a fundamental of nutrition support. Indirect calorimetry (IC) has been long recognized as the gold standard for assessing basal or resting energy expenditure (REE). The measurement of REE is recommended particularly in the situation where adjustment of energy provision is critical. The result of the IC measurement can lead to changes in treatment and since the change can be carried out immediately at the bedside, this may be considered as point-of-care testing. Beyond the nutritional aspects, studies of energy expenditure with IC have brought out more understanding of the metabolic changes during the natural course of diseases or conditions as well as those related to the intervention. The literature in various disease states has shown that changes in energy expenditure may reveal hidden metabolic information that might be translated into clinical information and have the potential of being both prognostic indicators and/or treatment targets.

Dietary management and supplementation with branched-chain amino acids in cirrhosis of the liver

One of the most important characteristics of malnutrition is the loss of muscle mass and the severe depletion of the protein reserve, secondarily affecting energy metabolism. That impacts nutritional status and the progression of disease-related complications. Nutritional treatment is one of the main factors in the comprehensive management of those patients. Achieving adequate energy intake that provides the macronutrients and micronutrients necessary to prevent or correct malnutrition is attempted through dietary measures. ESPEN, the European Society for Clinical Nutrition and Metabolism, recommends a caloric intake of 30-40kcal/kg/day, in which carbohydrates provide 45-60% of the daily energy intake and proteins supply 1.0-1.5g/kg/day. The remaining portion of the total energy expenditure should be covered by lipids. The administration of branched-chain amino acids has been shown to be beneficial not only in counteracting malnutrition, but also as a coadjuvant treatment in specific complications, thus playing a favorable role in outcome and quality of life. Therefore, branched-chain amino acids should be considered part of nutritional treatment in patients with advanced stages of cirrhosis of the liver, particularly in the presence of complications.

Effects of Late Evening Snack on Cirrhotic Patients: A Systematic Review and Meta-Analysis

Background

Energetic effects of late evening snack (LES) on cirrhotic patients were reported recently, but there was no quantitative analysis. In this meta-analysis, we reviewed and quantified the effects of LES on energy metabolism and substrate oxidation in the patients with cirrhosis, which will be of benefit for liver cirrhosis nutritional therapy.

Methods

A systematic search was conducted in PubMed, Embase, Web of Science, Elsevier, China National Knowledge Infrastructure, and Wanfang Database for relevant trials published until July 2017. These studies statistically were combined and analyzed by RevMan 5.3.

Results

Fourteen trials comprising 478 cases were eligible for analysis. The results showed that the respiratory quotient value (MD = 11.09) and carbohydrate oxidation value (MD = 0.05) significantly elevated with one week or with up to three weeks of LES treatment in cirrhotic patients (P < 0.05). Meanwhile, the levels of serum albumin (MD = 2.98) and cholinesterase (SMD = 1.09) were increased with LES administration for three weeks or that lasting twelve weeks (P < 0.05). However, there was no significant improvement for the levels of alanine aminotransferase (ALT) (P = 0.53), aspartate aminotransferase (AST) (P = 0.96), and total bilirubin (TB) (P = 0.32).

Conclusions

LES could improve the energy malnutrition state of cirrhotic patients. However, it may have little effect on reducing liver parenchymal injury indexes such as serum aminotransferase.

Major liver resection reduces nonprotein respiratory quotient and increases nonesterified fatty acid at postoperative day 14 in patients with hepatocellular carcinoma

BACKGROUND & AIMS

We reported decreased nonprotein respiratory quotient (npRQ) after liver resection in patients with hepatocellular carcinoma (HCC); however, whether liver resection volume affects energy metabolism in these patients is unclear. We aimed to examine the relationship between liver resection and energy metabolism indices.

METHODS

NpRQ was measured in 53 patients with HCC and seven with at the pre- and postoperative days. Patients were classified into four groups: Minor-lowICG group (n = 17): minor (subsegment or less) resection and low indocyanine green retention rate at 15 min (ICGR15) (<15%); Minor-highICG group (n = 18): minor resection and high ICGR15 (≥15%) and Major-lowICG group (n = 18): major (lobe) resection and low ICGR15 (<15%). We investigated dietary intake and blood biochemistry at energy measurement. The difference in npRQ and nonesterified fatty acid (NEFA) pre- and post-hepatectomy was shown as ΔnpRQ and ΔNEFA, respectively.

RESULTS

Compared with the preoperative values, npRQ significantly decreased in the Minor-highICG and Major-lowICG groups and NEFA significantly increased in the Major-lowICG group at postoperative day 14. In single regression analysis, ΔnpRQ significantly correlated with HCV infection and ΔNEFA with resection volume, HCV infection, and ICGR15. In multiple regression analysis, ΔNEFA significantly correlated with resection volume after adjusting for age, etiology, and ICGR15.

CONCLUSIONS

These results suggest that postoperative nutritional recovery is slower in major resection than in minor resection patients. Hence, nutritional care to prevent starvation is needed in major resection patients.

Exercise and physical activity for patients with end-stage liver disease: Improving functional status and sarcopenia while on the transplant waiting list

Sarcopenia and physical deconditioning are frequent complications in patients with cirrhosis and end-stage liver disease (ESLD). They are the end result of impaired dietary intake, chronic inflammation, altered macronutrient and micronutrient metabolism, and low physical activity. Frailty is the end result of prolonged sarcopenia and physical deconditioning. It severely affects a patient's functional status and presents in approximately 1 in 5 patients on the liver transplantation waiting list. Sarcopenia, poor physical fitness/cardiopulmonary endurance (CPE), and frailty are all associated with increased mortality in ESLD. Clinical trials addressing the usefulness of exercise in patients with cirrhosis have shown that it improves the metabolic syndrome, sarcopenia, CPE, health-related quality of life, and hepatic venous pressure gradient. Although evidence on the benefits of exercise on clinical outcomes derived from large clinical trials is still missing, based on existing literature from multiple medical subspecialties, we believe that an exercise program coupled to a tailored nutritional intervention benefits both cardiopulmonary and musculoskeletal functions, ultimately translating into improved functional status, sense of well-being, and possibly less complications from portal hypertension. In conclusion, although supervised exercise training is the prevailing approach to manage ESLD patients, such intervention is not sustainable or feasible for most patients. Innovative home-based physical activity interventions may be able to effectively reach a larger number of patients. Liver Transplantation 24 122-139 2018 AASLD.

Nutritional Therapy in Liver Transplantation

Protein-energy malnourishment is commonly encountered in patients with end-stage liver disease who undergo liver transplantation. Malnutrition may further increase morbidity, mortality and costs in the post-transplantation setting. The importance of carefully assessing the nutritional status during the work-up of patients who are candidates for liver replacement is widely recognized. The metabolic abnormalities induced by liver failure render the conventional assessment of nutritional status to be challenging. Preoperative loss of skeletal muscle mass, namely, sarcopenia, has a significant detrimental impact on post-transplant outcomes. It is essential to provide sufficient nutritional support during all phases of liver transplantation. Oral nutrition is preferred, but tube enteral nutrition may be required to provide the needed energy intake. Herein, the latest currently employed perioperative nutritional interventions in liver transplant recipients are thoroughly illustrated including synbiotics, micronutrients, branched-chain amino acid supplementation, immunonutrition formulas, fluid and electrolyte balance, the offering of nocturnal meals, dietary counselling, exercise and rehabilitation.

Prognostic significance of nonprotein respiratory quotient in patients with liver cirrhosis

The aim of this study was to examine the effect of nonprotein respiratory quotient (npRQ), as assessed using indirect calorimetry, on clinical outcomes in patients with liver cirrhosis (LC). A total of 244 LC patients were evaluated in this study. For the univariate analysis, for each continuous variable, the optimal cutoff value that maximized the sum of sensitivity and specificity was selected using receiver operating curve (ROC) analysis for survival. There were 137 men and 107 women with the median (range) age of 67 (25-90) years. Indirect calorimetry indicated that 54 patients (22.1%) had hepatocellular carcinoma (HCC) on radiological findings and 59 patients (24.2%) had protein energy malnutrition, as defined by npRQ <0.85 and serum albumin level <3.5 g/dL. In ROC analysis of npRQ for survival, the optimal cutoff point of npRQ was 0.849 for all cases (area under the ROC = 0.61272; sensitivity, 66.22%; and specificity, 57.06%). The median follow-up periods after indirect calorimetry were 4.35 years (range, 1.01-9.66 years) in patients with npRQ ≥0.85 (n = 122) and 3.71 years (range, 0.19-9.51 years) in patients with npRQ <0.85 (n = 122). The 1-, 3-, and 5-year cumulative OS rates in patients with npRQ ≥0.85 were 100%, 87.79%, and 77.24%, respectively, whereas those in patients with npRQ <0.85 were 94.26%, 73.65% and 57.78%, respectively (P = 0.0004). In the multivariate analysis, presence of HCC (P = 0.0045), body mass index (P < 0.0001), serum albumin (P = 0.0441), prothrombin time (P = 0.0463), npRQ (P = 0.0024), estimated glomerular filtration rate (P = 0.0086), and des-γ-carboxy prothrombin (P = 0.0268) were found to be significant predictors associated with OS. For all cases, risk stratification for survival was well performed using these significant variables. In conclusion, npRQ value, as assessed by indirect calorimetry, can be helpful for predicting clinical outcomes for LC patients.

Effects of oral carbohydrate with amino acid solution on the metabolic status of patients in the preoperative period: a randomized, prospective clinical trial

Objective

Enhanced recovery after surgery is increasingly desired nowadays, and preoperative nutrient intake may be beneficial for this purpose. In this study, we investigated whether the intake of preoperative carbohydrate with amino acid (ONS) solution can improve starvation status and lipid catabolism before the induction of anesthesia.

Methods

This randomized, prospective clinical trial included 24 patients who were divided into two groups before surgery under general anesthesia: a control group, comprising patients who fasted after their last meal the day before surgery (permitted to drink only water), and an ONS group, comprising patients who consumed ONS solution 2 h before surgery. Biochemical markers, the respiratory quotient, and psychosomatic scores were assessed at the initiation of anesthesia.

Results

Compared with the control group, the ONS group showed significantly lower serum free fatty acid levels [control group: 828 (729, 1004) µEq/L, ONS group: 479 (408, 610) µEq/L, P = 0.0002, median (25th, 75th percentile)] and total ketone bodies [control group: 119 (68, 440) µmol/L, ONS group: 40 [27, 64] µmol/L, P = 0.037]. In addition, analysis using the Visual Analog Scale showed higher preoperative scores for anxiety, hunger, and thirst for the control group, with no differences in any other measure of subjective well-being between groups.

Conclusions

The results of this study suggest that preoperative ONS intake improves lipid catabolism and starvation status before the induction of anesthesia. Furthermore, it can provide better preoperative mental health compared with complete fasting.

Evidence-based clinical practice guidelines for liver cirrhosis 2015

The Japanese Society of Gastroenterology revised the evidence-based clinical practice guidelines for liver cirrhosis in 2015. Eighty-three clinical questions were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. Manual searching of the latest important literature was added until August 2015. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This digest version in English introduces selected clinical questions and statements related to the management of liver cirrhosis and its complications. Branched-chain amino acids relieve hypoalbuminemia and hepatic encephalopathy and improve quality of life. Nucleoside analogues and peginterferon plus ribavirin combination therapy improve the prognosis of patients with hepatitis B virus related liver cirrhosis and hepatitis C related compensated liver cirrhosis, respectively, although the latter therapy may be replaced by direct-acting antivirals. For liver cirrhosis caused by primary biliary cirrhosis and active autoimmune hepatitis, urosodeoxycholic acid and steroid are recommended, respectively. The most adequate modalities for the management of variceal bleeding are the endoscopic injection sclerotherapy for esophageal varices and the balloon-occluded retrograde transvenous obliteration following endoscopic obturation with cyanoacrylate for gastric varices. Beta-blockers are useful for primary prophylaxis of esophageal variceal bleeding. The V2 receptor antagonist tolvaptan is a useful add-on therapy in careful diuretic therapy for ascites. Albumin infusion is useful for the prevention of paracentesis-induced circulatory disturbance and renal failure. In addition to disaccharides, the nonabsorbable antibiotic rifaximin is useful for the management of encephalopathy. Anticoagulation therapy is proposed for patients with acute-onset or progressive portal vein thrombosis.

Changes in portal blood flow and liver functions in cirrhotics during Ramadan fasting in the summer; a pilot study

AIM

Assessment of short term changes in portal blood flow and long term changes in liver functions in cirrhotic patients who chose to fast during the month of Ramadan in summer.

BACKGROUND

During Ramadan, healthy Muslims obligated to fast from predawn to sunset.

PATIENTS AND METHODS

Forty cirrhotic patients intended to fast during the month of Ramadan in the year 2014, were examined by Congestion index (CI) as a non-invasive indicator of short term changes in the portal blood flow, while liver function tests were determined as an indicator of long term changes in liver functions.

RESULTS

A total of 38 patients completed the whole month fasting and two patients discontinued fasting due to variceal bleeding. The complicated patients were 7. CI showed a statistically significant increase from fasting to postprandial status (P<0.001), with statistically significant increases from fasting to postprandial status in Child class A (P<0.001), and B (P<0.001). We did not find a statistical significance between patients with complications and those without complications (P=0.6). There was a statistically significant rise in the serum bilirubin after Ramadan. Deterioration noticed as advanced Child classes, development of lower limb edema, increasing ascites, increasing jaundice and overt encephalopathy.

CONCLUSION

Cirrhotic patients showed significant short-term changes in the portal blood flow. However, these changes are not linked to complications or deterioration of liver functions and accommodated especially in patients with Child class A and B. Child class C patients should not fast.

The Molecular Circadian Clock and Alcohol-Induced Liver Injury

Emerging evidence from both experimental animal studies and clinical human investigations demonstrates strong connections among circadian processes, alcohol use, and alcohol-induced tissue injury. Components of the circadian clock have been shown to influence the pathophysiological effects of alcohol. Conversely, alcohol may alter the expression of circadian clock genes and the rhythmic behavioral and metabolic processes they regulate. Therefore, we propose that alcohol-mediated disruption in circadian rhythms likely underpins many adverse health effects of alcohol that cut across multiple organ systems. In this review, we provide an overview of the circadian clock mechanism and showcase results from new studies in the alcohol field implicating the circadian clock as a key target of alcohol action and toxicity in the liver. We discuss various molecular events through which alcohol may work to negatively impact circadian clock-mediated processes in the liver, and contribute to tissue pathology. Illuminating the mechanistic connections between the circadian clock and alcohol will be critical to the development of new preventative and pharmacological treatments for alcohol use disorders and alcohol-mediated organ diseases.

Two randomized controlled studies comparing the nutritional benefits of branched-chain amino acid (BCAA) granules and a BCAA-enriched nutrient mixture for patients with esophageal varices after endoscopic treatment

BACKGROUND

The usefulness of branched-chain amino acid (BCAA) granules and BCAA-enriched nutrient mixtures for patients with liver cirrhosis is often reported. However, no randomized controlled studies have investigated the usefulness of these supplements in the nutritional intervention of cirrhotic patients receiving endoscopic treatment for esophageal varices.

METHODS

Patients without BCAA before endoscopic treatment were divided into study 1, and those who received BCAA were divided into study 2. In study 1, 44 eligible patients were divided into a control group (n = 13), a general liquid nutrient (snack) group (n = 15), and a BCAA-enriched nutrient mixture (BCAA-EN) group (n = 16). In study 2, 48 eligible patients were divided into a BCAA group (n = 24) and a BCAA-EN group (n = 24). The nutritional status including non-protein respiratory quotient (NPRQ) levels, weight gain, and albumin were evaluated on days 0, 7, and 50.

RESULTS

In study 1, the BCAA-EN group showed significant improvement in NPRQ levels on day 7 as compared with the snack group. In study 2, the BCAA-EN group showed significant improvement in NPRQ levels on day 7 and in weight levels on day 50 relative to the BCAA group, while the BCAA group showed improved serum albumin levels on day 7 compared to the BCAA-EN group.

CONCLUSIONS

The BCAA-enriched nutrient mixture maintained NPRQ and weight in cirrhotic patients. Our findings suggest that supplements including both BCAA and a nutritional energy supplement would be beneficial for cirrhotic patients undergoing endoscopic treatment for esophageal varices.

Pre- and postoperative nutritional assessment and health-related quality of life in recipients of living donor liver transplantation

AIM

The nutritional state of living donor liver transplantation (LDLT) recipients is one of the most important factors affecting postoperative outcome. Although the assessment of health-related quality of life (HRQOL) is of increasing importance, few studies have examined this in conjunction with LDLT recipient nutritional state.

METHODS

Ten LDLT recipients with end-stage liver disease were recruited for this study. Measurements of energy expenditure, anthropometrics and laboratory data were performed before and 1, 6 and 12-24 months after LDLT. HRQOL was measured by using the 36-item Short-Form (SF-36) before and 1, 3, 6 and 12-24 months after LDLT.

RESULTS

The preoperative value of non-protein respiratory quotient (npRQ) was 0.796 ± 0.026 and it increased significantly after the operation. Serum non-esterified fatty acid (NEFA) levels were high in the preoperative state, but had significantly decreased 1 month after the operation. A negative correlation between npRQ and NEFA was observed throughout the study period. Cholinesterase and albumin levels improved to normal levels within 6 and 12-24 months, respectively. The recovery of the physical component summary of the SF-36 was observed after the improvement of all domains of laboratory data and energy metabolism based on the nutritional state.

CONCLUSION

This study demonstrated that the recovery of metabolic function, laboratory data and HRQOL in LDLT recipients are variable, and it took more than 6 months to normalize the liver protein synthetic capacity and physical HRQOL score periods. Therefore, long-term nutritional support is required in LDLT recipients.

Free fatty acid as a marker of energy malnutrition in liver cirrhosis

AIM

Protein-energy malnutrition is frequently observed in patients with liver cirrhosis (LC). Non-protein respiratory quotient (npRQ) measured by indirect calorimetry is a good marker to estimate energy malnutrition, and predicts the prognosis of patients with LC. However, measurement of npRQ is limited because of the high cost of indirect calorimetry. Our aim was to find out an alternative marker to npRQ that can be used in the routine clinical setting.

METHODS

One hundred and fifty-six patients with LC were enrolled in this study. Indirect calorimetry and blood examinations were conducted after overnight fasting, and anthropometry was performed by an expert dietician. The correlation between npRQ and other parameters were calculated by simple and multiple regression analysis. Receiver-operator curve (ROC) analysis was used to identify the cut-off value that would best predict the threshold npRQ of 0.85.

RESULTS

Plasma levels of free fatty acid (FFA) was significantly correlated with npRQ value by simple (r = -0.39, P < 0.0001) and multiple regression analysis (t = -2.96, P = 0.0052). Free fatty acid rose in parallel with the increasing disease severity as defined by Child-Pugh classification (P < 0.05). FFA was also correlated with increasing oxidation rate of fat (r = 0.38, P < 0.0001) and decreasing oxidation rate of carbohydrate (r = -0.39, P < 0.0001). The cut-off value of FFA to predict npRQ = 0.85 was 660 μEq/L by ROC analysis.

CONCLUSION

FFA is a useful alternative marker to represent npRQ in patients with LC.

Effect of a carbohydrate-containing late-evening snack on energy metabolism and fasting substrate utilization in adults with acute-on-chronic liver failure due to Hepatitis B

BACKGROUND/OBJECTIVES

This study investigates the effects of a carbohydrate (CHO; lotus-root starch) predominant, late-evening snack (LES), containing 200 kcal (50 g CHO) on fasting resting energy expenditure (REE) and nutrient oxidation in hospitalized adults with acute-on-chronic liver failure (ACLF).

SUBJECTS/METHODS

Adults with ACLF were randomized to receive daily LES (treatment; n=35) or standard care (n=35; non-supplemented control) for 14 days. REE and respiratory quotient (RQ) were measured by indirect calorimetry, nutrient oxidation (CHO, protein and fat), intake and biochemical parameters were measured in both groups at baseline and after 14 days using validated techniques. Disease severity was measured using the model for end-stage liver disease (MELD).

RESULTS

No significant differences in macronutrient intake, anthropometric, demographic characteristics or MELD scores were observed between groups at baseline (P>0.05). Fasting RQ was significantly higher in the LES supplemented verses the control group after 2 weeks (P=0.02). CHO oxidation was significantly higher (P=0.001) and fat oxidation (P=0.02) was lower in the LES-supplemented group when compared with controls after 2 weeks. Fasting RQ and REE in the LES-supplemented group increased significantly (0.83 verses 0.88; P=0.007/1301±409 vs 1687±718 kcal/day; P=0.02) in patients with MELD scores 30 when compared with patients with MELD scores >30 (0.82 verses 0.84; P=0.27/ 1361±405 vs 1437±429 kcal/day; P=0.67) after supplementation.

CONCLUSIONS

A carbohydrate-predominant LES is associated with increases in fasting carbohydrate oxidation, REE and reductions in fat oxidation in adults with ACLF. Therapeutic strategies utilizing LES may promote improved nutritional status in adults with ACLF.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Nutritional assessments for ordinary medical care in patients with chronic liver disease

AIM

  In patients with chronic liver disease who are at risk of malnutrition, simple and useful assessments for nutritional status should be established for ordinary medical care. The prognostic nutritional index (PNI) and controlling nutritional status (CONUT) are simple assessments constructed of only two or three laboratory data. We aimed to describe the potential of PNI and CONUT as a nutritional assessment tool in patients with chronic liver disease.

METHODS

  We enrolled 165 patients, aged 18-85 years, with chronic liver disease. These patients were nutritionally assessed by PNI or CONUT, demonstrating the association with the severity of chronic liver disease or anthropometric values.

RESULTS

  The value of PNI or CONUT was significantly associated with the severity of chronic liver disease (P < 0.001, respectively). In addition, the value of CONUT was significantly associated with all the anthropometric values such as body mass index (BMI, P < 0.05), mid-arm circumference (AC, P < 0.001), mid-arm muscle circumference (AMC, P < 0.001), and triceps skinfold thickness (TSF, P < 0.001), whereas the value of PNI was significantly associated with the values of AC (P < 0.01), AMC (P < 0.05) and TSF (P < 0.05). Approximately 80% of cirrhotic patients were assessed by PNI or CONUT to have obvious malnutrition.

CONCLUSION

  PNI and CONUT are potential tools for nutritional assessment in patients with chronic liver disease, especially for ordinary medical care, because of their simplicity.

Nutrition therapy for liver diseases based on the status of nutritional intake

The dietary intake of patients with nonalcoholic fatty liver disease (NAFLD) is generally characterized by high levels of carbohydrate, fat, and/or cholesterol, and these dietary patterns influence hepatic lipid metabolism in the patients. Therefore, careful investigation of dietary habits could lead to better nutrition therapy in NAFLD patients. The main treatment for chronic hepatitis C (CHC) is interferon-based antiviral therapy, which often causes a decrease in appetite and energy intake; hence, nutritional support is also required during therapy to prevent undernourishment, treatment interruption, and a reduction in quality of life. Moreover, addition of some nutrients that act to suppress viral proliferation is recommended. As a substitutive treatment, low-iron diet therapy, which is relatively safe and effective for preventing hepatocellular carcinoma, is also recommended for CHC patients. Some patients with liver cirrhosis (LC) have decreased dietary energy and protein intake, while the number of LC patients with overeating and obesity is increasing, indicating that the nutritional state of LC patients has a broad spectrum. Therefore, nutrition therapy for LC patients should be planned on an assessment of their complications, nutritional state, and dietary intake. Late evening snacks, branched-chain amino acids, zinc, and probiotics are considered for effective nutritional utilization.

Late evening snack: exploiting a period of anabolic opportunity in cirrhosis

BACKGROUND AND AIM

Cirrhosis is a state of accelerated starvation with impaired protein synthesis. Increased rate of gluconeogenesis and alterations in skeletal muscle signaling pathways result in anabolic resistance and consequent loss of muscle mass or sarcopenia in cirrhosis. Late evening snack (LES) is an intervention to reduce the postabsorptive (fasting) phase with the potential to improve substrate utilization and reverse sarcopenia. Published reports were evaluated to examine the effect of LES on regulation of substrate utilization (short-term studies) and nutritional outcomes (long-term studies).

METHODS

PubMed, EMBASE, Google scholar and OVID databases were searched. All studies published on LES in cirrhosis were included. Studies that included few (n < 3) subjects and patients with hepatocellular carcinoma were excluded.

RESULTS

Late evening snack decreased lipid oxidation and improved nitrogen balance, irrespective of the composition or type of formulation used. Daytime isocaloric isonitrogenous snacks did not have the metabolic or clinical benefit of LES. LES decreased skeletal muscle proteolysis. No studies have examined its effect on muscle protein synthesis. There was inconsistent translation into an increase in lean body or skeletal muscle mass. Improved quality of life occurs but decreased mortality or need for transplantation has not been reported. The optimal composition of LES has not been defined, but based on mechanistic considerations, a branched chain supplemented LES holds most promise.

CONCLUSIONS

Late evening snack holds the most promise as an intervention to reverse anabolic resistance and sarcopenia of cirrhosis with improved quality of life in patients with cirrhosis. Long term benefit and improved survival need critical evaluation.

Cytokines, liver fibrosis, and principles of nutritional support in patients with liver fibrosis

The rapid development of molecular biology has provided new paths for and led to great breakthroughs in the treatment of liver fibrosis. Now the research of targets for anti-fibrosis therapy mainly focuses on hepatic stellate cells (HSC) and cytokines related to HSC activation. Researchers are getting more concerned about the features of nutritional metabolism in patients with liver fibrosis and their relationship with prognosis because of special roles the liver plays in nutritional metabolism. Reasonable principles of nutritional support can help ameliorate symptoms, reduce complications and facilitate recovery in patients with liver fibrosis.

Breakfast improves cognitive function in cirrhotic patients with cognitive impairment

BACKGROUND

Cognitive disturbances are relatively common in patients with liver disease. High protein load precipitates hepatic encephalopathy in cirrhotic patients. Minimal hepatic encephalopathy (MHE) is a prevalent neurocognitive complication of cirrhosis.

OBJECTIVE

Because the influence of nutritional factors on the progression of cognitive impairment has not been explored in depth, this study aimed to investigate the effect on cognition of acute metabolic changes induced by breakfast consumption.

DESIGN

Twenty-one subjects (10 women) with Child A cirrhosis and 21 age- and sex-matched healthy controls were enrolled. Patients and controls were divided into 2 groups: those receiving a breakfast of 500 kcal and 21 g protein and those receiving no breakfast. Serum ammonia concentrations and cognitive functions were studied (Mindstreams; NeuroTrax, Fresh Meadows, NY) before and 2 h after breakfast. A mixed model was used to analyze the data.

RESULTS

At baseline, cirrhotic patients had significantly lower total scores and significantly lower subscores (P < 0.015 global cognitive score) in 4 of 7 cognitive categories, which is indicative of MHE. Patients with hyperammonemia (>85 mug/dL) scored significantly lower for attention than did patients with normal serum ammonia concentrations (P < 0.003). After 2 h, MHE patients and controls responded differently to breakfast consumption with regard to attention and executive functions (P < 0.003 and P < 0.04, respectively). Although patients' scores improved after breakfast consumption, despite an increase in serum ammonia, healthy controls who continued to fast performed better.

CONCLUSIONS

Chronic hyperammonemia may negatively affect attention. Eating breakfast improves attention and executive functions of patients with MHE. Prolonged periods of starvation may be partly responsible for these changes. This trial was registered at clinicaltrials.gov as NCT01083446.

Effect of long-term late-evening snack on health-related quality of life in cirrhotic patients

AIM

In patients with liver cirrhosis, abnormal energy metabolism induces low health-related quality of life (HRQOL) scores. However, late-evening snack (LES) prevents morning starvation in cirrhotic patients. Our aim is to assess the effect of long-term LES on HRQOL in cirrhotic patients, using the 36-item Short Form (SF-36) health survey.

METHODS

Thirty-nine cirrhotic patients classified as Child-Pugh grade A were recruited. The patients were randomly divided into two groups: 24 were assigned to the non-LES group and 15 to the LES group. SF-36 scores, anthropometric data and serum biochemical parameters were examined in the non-LES and LES groups at 0, 6 and 12 months.

RESULTS

Neither anthropometric data nor laboratory data showed significant differences between the non-LES and the LES groups at 0, 6 and 12 months. The role-emotional (RE) HRQOL scores at 6 months and mental health (MH) scores at 6 and 12 months were significantly reduced from the baseline level in the non-LES group. In contrast, these scores remained unchanged in the LES group. General health perception (GH) scores at 12 months, RE at 6 months and MH at 6 and 12 months in the LES group were significantly higher than those of the non-LES group.

CONCLUSION

Long-term LES administration may be helpful in maintaining higher HRQOL in patients with cirrhosis.

Effects of a late evening snack combined with alpha-glucosidase inhibitor on liver cirrhosis

AIM

A late evening snack (LES) is recommended for protein-energy malnutrition in patients with liver cirrhosis. However, many cases of liver cirrhosis have accompanying impaired glucose tolerance and there are concerns that LESs might aggravate glucose intolerance. In this study, we concomitantly used an alpha-glucosidase inhibitor with a LES and examined the effects on glucose tolerance. In addition, we examined whether or not there was an improvement in energy metabolism by slowing glucose absorption with the concomitant use of the alpha-glucosidase inhibitor.

METHODS

The subjects were 11 patients with liver cirrhosis. From before the study, all the patients had been taking a LES supplementation with a branched-chain amino acid (BCAA)-enriched nutrient mixture. The patients were started on the concomitant use of alpha-glucosidase inhibitor (0.2 mg) taken just prior to the LES. The change of glucose tolerance and energy metabolism were examined using a 75-g oral glucose tolerance test and indirect calorimetry.

RESULTS

One week and three months after the start of the concomitant use of the alpha-glucosidase inhibitor, the area under the concentration curve for plasma glucose was significantly decreased. Three months after the concomitant use, the non-protein respiratory quotient was significantly improved. There were no serious side effects during the follow-ups.

CONCLUSION

The concomitant use of the alpha-glucosidase inhibitor use with LES showed the possibility of improving glucose tolerance and energy metabolism. In patients with impaired glucose tolerance, the concomitant use of an alpha-glucosidase inhibitor with LES might be a useful measure for nutritional management.

Resting energy expenditure and glucose, protein and fat oxidation in severe chronic virus hepatitis B patients

AIM: To study and determine the resting energy expenditure (REE) and oxidation rates of glucose, fat and protein in severe chronic hepatitis B patients.

METHODS: A total of 100 patients with liver diseases were categorized into three groups: 16 in the acute hepatitis group, 56 in the severe chronic hepatitis group, and 28 in the cirrhosis group. The REE and the oxidation rates of glucose, fat and protein were assessed by indirect heat measurement using the CCM-D nutritive metabolic investigation system.

RESULTS: The REE of the severe chronic hepatitis group (20.7 ± 6.1 kcal/d per kg) was significantly lower than that of the acute hepatitis group (P = 0.014). The respiratory quotient (RQ) of the severe chronic hepatitis group (0.84 ± 0.06) was significantly lower than that of the acute hepatitis and cirrhosis groups (P = 0.001). The glucose oxidation rate of the severe hepatitis group (39.2%) was significantly lower than that of the acute hepatitis group and the cirrhosis group (P < 0.05), while the fat oxidation rate (39.8%) in the severe hepatitis group was markedly higher than that of the other two groups (P < 0.05). With improvement of liver function, the glucose oxidation rate increased from 41.7% to 60.1%, while the fat oxidation rate decreased from 26.3% to 7.6%.

CONCLUSION: The glucose oxidation rate is significantly decreased, and a high proportion of energy is provided by fat in severe chronic hepatitis. These results warrant a large clinical trail to assess the optimal nutritive support therapy for patients with severe liver disease.