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Chapman B, Wong D, Sinclair M, Hey P, Terbah R, Gow P, Majumdar A, Testro A. Reversing malnutrition and low muscle strength with targeted enteral feeding in patients awaiting liver transplant: A randomized controlled trial. Hepatology 2024:01515467-990000000-00794. [PMID: 38456800 DOI: 10.1097/hep.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/23/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND AIMS Most patients with decompensated cirrhosis fail to meet their nutrition targets. The impact of nasogastric feeding (NGF) on malnutrition in cirrhosis remains unknown. This study aims to assess the impact of pretransplant NGF on pre-liver transplant and post-liver transplant outcomes. APPROACH AND RESULTS This single-center, prospective randomized controlled trial of 55 patients with severe malnutrition and low handgrip strength (HGS) compared a standard high-energy high-protein diet to diet plus supplemental nocturnal NGF while awaiting transplant. The primary outcome was a change in HGS. The median age was 58.5 years (IQR: 51.1-64), median MELD was 24 (20-28.5), and 32 (58%) patients were male. The median duration of NGF was 63.0 days (34.5-127), following which time the median between-group difference in HGS was 3.6 kg (95% CI: 1.7-5.2, p <0.001), an increase of 20% from baseline. Mid-upper-arm circumference, triceps skinfold, and immune function all increased significantly with NGF. Muscle and nutritional parameters continued to improve with increasing duration of feeding. NGF significantly increased daily energy intake between groups by 1285 kcal (95% CI: 860-1677) and protein intake by 51 g (95% CI: 32-71) (both p <0.001). All NGF patients met >100% of their measured nutritional requirements. Posttransplant clinical outcomes were similar between groups. CONCLUSIONS Targeted enteral feeding before liver transplant improves HGS, anthropometry, and immune function in severely malnourished patients with cirrhosis. These findings provide a strong rationale for early consideration of NGF to reverse malnutrition and improve muscle strength. Appropriately powered studies should explore whether NGF can also impact clinically relevant outcomes including pretransplant and posttransplant mortality.
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Affiliation(s)
- Brooke Chapman
- Department of Nutrition and Dietetics, Austin Health, Heidelberg, Victoria, Australia
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Darren Wong
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Penelope Hey
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Ryma Terbah
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Avik Majumdar
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Adam Testro
- Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
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Jophlin LL, Singal AK, Bataller R, Wong RJ, Sauer BG, Terrault NA, Shah VH. ACG Clinical Guideline: Alcohol-Associated Liver Disease. Am J Gastroenterol 2024; 119:30-54. [PMID: 38174913 PMCID: PMC11040545 DOI: 10.14309/ajg.0000000000002572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/04/2023] [Indexed: 01/05/2024]
Abstract
ABSTRACT Alcohol-associated liver disease (ALD) is the most common cause of advanced hepatic disease and frequent indication for liver transplantation worldwide. With harmful alcohol use as the primary risk factor, increasing alcohol use over the past decade has resulted in rapid growth of the ALD-related healthcare burden. The spectrum of ALD ranges from early asymptomatic liver injury to advanced disease with decompensation and portal hypertension. Compared with those with other etiologies of liver disease, patients with ALD progress faster and more often present at an advanced stage. A unique phenotype of advanced disease is alcohol-associated hepatitis (AH) presenting with rapid onset or worsening of jaundice, and acute on chronic liver failure in severe forms conveying a 1-month mortality risk of 20%-50%. The model for end stage disease score is the most accurate score to stratify AH severity (>20 defined as severe disease). Corticosteroids are currently the only available therapeutic with proven efficacy for patients with severe AH, providing survival benefit at 1 month in 50%-60% of patients. Abstinence of alcohol use, a crucial determinant of long-term outcomes, is challenging to achieve in ALD patients with concurrent alcohol use disorder (AUD). As patients with ALD are rarely treated for AUD, strategies are needed to overcome barriers to AUD treatment in patients with ALD and to promote a multidisciplinary integrated care model with hepatology, addiction medicine providers, and social workers to comprehensively manage the dual pathologies of liver disease and of AUD. Liver transplantation, a definitive treatment option in patients with advanced cirrhosis, should be considered in selected patients with AH, who are unresponsive to medical therapy and have a low risk of relapse to posttransplant alcohol use. Level of evidence and strength of recommendations were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations system. This guideline was developed under the American College of Gastroenterology Practice Parameters Committee.
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Affiliation(s)
- Loretta L Jophlin
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville Health, Louisville, Kentucky, USA
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, University of South Dakota, Sioux Falls, South Dakota, USA
| | - Ramon Bataller
- Liver Unit, Department of Digestive and Metabolic Diseases, Hospital Clinic, Barcelona, Spain
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | - Bryan G Sauer
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Norah A Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Chapman B, Wong D, Whitcher B, Sinclair M, Gow P, Majumdar A, Testro A. Redefining Nutritional Requirements in End-Stage Liver Disease: Towards a Personalized Approach. Nutrients 2023; 15:4770. [PMID: 38004164 PMCID: PMC10675823 DOI: 10.3390/nu15224770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Malnutrition is ubiquitous in cirrhotic patients presenting for liver transplant (LT). Providing an appropriate energy prescription is fundamental to effective nutrition therapy. We aimed to compare measured energy expenditure (mEE) with predicted energy expenditure (pEE) in patients awaiting LT and determine clinical factors associated with mEE. In this prospective observational study, energy expenditure was measured by indirect calorimetry in 110 adult patients referred for LT and predicted by commonly utilized equations (Harris-Benedict, Schofield, and EASL guidelines). Nutritional status, anthropometry, muscle function, biochemical and clinical data were also collected. The median model for end-stage liver disease (MELD) was 19 (IQR 13, 25), and the majority were Child-Pugh B (51%) or C (37%). Malnutrition was evident in 85%. Median mEE by calorimetry was 1756 (1531, 2104) kcal/d and significantly higher than pEE as per Harris-Benedict 1480 (1322, 1722) kcal/d and Schofield 1474 (1349, 1723) kcal/d (both p < 0.001), but lower than EASL guidelines (35 kcal/kg) when an activity factor was applied to mEE; 2283 (1990, 2735) kcal/d versus 2590 (2178, 3010) kcal/d (p < 0.001). Hypermetabolism (mEE:pEE > 1.2) was evident in 48% of the cohort. Multivariate analysis found MELD, Child-Pugh class, diuretic use, and severe malnutrition to be independent predictors of hypermetabolism. A new liver-specific predictive model has been developed, showing superior agreement with mEE than common predictive equations. In conclusion, there is a poor correlation between mEE and pEE in patients awaiting LTs, and hypermetabolism is common. Relying on historical predictive equations in this patient population may result in significant under or over-feeding. A tailored energy prescription based on indirect calorimetry or a liver-specific predictive model is recommended for LT candidates.
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Affiliation(s)
- Brooke Chapman
- Department of Nutrition and Dietetics, Austin Health, Heidelberg, VIC 3084, Australia
- Liver Transplant Unit, Austin Health, Heidelberg, VIC 3084, Australia; (D.W.); (B.W.); (M.S.); (P.G.); (A.M.); (A.T.)
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Darren Wong
- Liver Transplant Unit, Austin Health, Heidelberg, VIC 3084, Australia; (D.W.); (B.W.); (M.S.); (P.G.); (A.M.); (A.T.)
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Bethany Whitcher
- Liver Transplant Unit, Austin Health, Heidelberg, VIC 3084, Australia; (D.W.); (B.W.); (M.S.); (P.G.); (A.M.); (A.T.)
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, Heidelberg, VIC 3084, Australia; (D.W.); (B.W.); (M.S.); (P.G.); (A.M.); (A.T.)
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Health, Heidelberg, VIC 3084, Australia; (D.W.); (B.W.); (M.S.); (P.G.); (A.M.); (A.T.)
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Avik Majumdar
- Liver Transplant Unit, Austin Health, Heidelberg, VIC 3084, Australia; (D.W.); (B.W.); (M.S.); (P.G.); (A.M.); (A.T.)
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Adam Testro
- Liver Transplant Unit, Austin Health, Heidelberg, VIC 3084, Australia; (D.W.); (B.W.); (M.S.); (P.G.); (A.M.); (A.T.)
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia
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Espina S, Casas-Deza D, Bernal-Monterde V, Domper-Arnal MJ, García-Mateo S, Lué A. Evaluation and Management of Nutritional Consequences of Chronic Liver Diseases. Nutrients 2023; 15:3487. [PMID: 37571424 PMCID: PMC10421025 DOI: 10.3390/nu15153487] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023] Open
Abstract
Liver diseases are the major predisposing conditions for the development of malnutrition, sarcopenia, and frailty. Recently, the mechanism of the onset of these complications has been better established. Regardless of the etiology of the underlying liver disease, the clinical manifestations are common. The main consequences are impaired dietary intake, altered macro- and micronutrient metabolism, energy metabolism disturbances, an increase in energy expenditure, nutrient malabsorption, sarcopenia, frailty, and osteopathy. These complications have direct effects on clinical outcomes, survival, and quality of life. The nutritional status should be assessed systematically and periodically during follow-up in these patients. Maintaining and preserving an adequate nutritional status is crucial and should be a mainstay of treatment. Although general nutritional interventions have been established, special considerations are needed in specific settings such as decompensated cirrhosis, alcohol-related liver disease, and metabolic-dysfunction-associated fatty liver disease. In this review, we summarize the physiopathology and factors that impact the nutritional status of liver disease. We review how to assess malnutrition and sarcopenia and how to prevent and manage these complications in this setting.
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Affiliation(s)
- Silvia Espina
- Gastroenterology Department, Miguel Servet University Hospital, 50009 Zaragoza, Spain; (S.E.); (D.C.-D.); (V.B.-M.)
- Adipocyte and Fat Biology Laboratory (AdipoFat), Translational Research Unit, Miguel Servet University Hospital, 50009 Zaragoza, Spain
- Instituto de Investigación Sanitaria (IIS) Aragon, 50009 Zaragoza, Spain; (M.J.D.-A.); (S.G.-M.)
| | - Diego Casas-Deza
- Gastroenterology Department, Miguel Servet University Hospital, 50009 Zaragoza, Spain; (S.E.); (D.C.-D.); (V.B.-M.)
- Adipocyte and Fat Biology Laboratory (AdipoFat), Translational Research Unit, Miguel Servet University Hospital, 50009 Zaragoza, Spain
- Instituto de Investigación Sanitaria (IIS) Aragon, 50009 Zaragoza, Spain; (M.J.D.-A.); (S.G.-M.)
| | - Vanesa Bernal-Monterde
- Gastroenterology Department, Miguel Servet University Hospital, 50009 Zaragoza, Spain; (S.E.); (D.C.-D.); (V.B.-M.)
- Adipocyte and Fat Biology Laboratory (AdipoFat), Translational Research Unit, Miguel Servet University Hospital, 50009 Zaragoza, Spain
- Instituto de Investigación Sanitaria (IIS) Aragon, 50009 Zaragoza, Spain; (M.J.D.-A.); (S.G.-M.)
| | - María José Domper-Arnal
- Instituto de Investigación Sanitaria (IIS) Aragon, 50009 Zaragoza, Spain; (M.J.D.-A.); (S.G.-M.)
- Gastroenterology Department, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
| | - Sandra García-Mateo
- Instituto de Investigación Sanitaria (IIS) Aragon, 50009 Zaragoza, Spain; (M.J.D.-A.); (S.G.-M.)
- Gastroenterology Department, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
| | - Alberto Lué
- Instituto de Investigación Sanitaria (IIS) Aragon, 50009 Zaragoza, Spain; (M.J.D.-A.); (S.G.-M.)
- Gastroenterology Department, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
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Moreau R, Tonon M, Krag A, Angeli P, Berenguer M, Berzigotti A, Fernandez J, Francoz C, Gustot T, Jalan R, Papp M, Trebicka J. EASL Clinical Practice Guidelines on acute-on-chronic liver failure. J Hepatol 2023; 79:461-491. [PMID: 37364789 DOI: 10.1016/j.jhep.2023.04.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/19/2023] [Indexed: 06/28/2023]
Abstract
Acute-on-chronic liver failure (ACLF), which was described relatively recently (2013), is a severe form of acutely decompensated cirrhosis characterised by the existence of organ system failure(s) and a high risk of short-term mortality. ACLF is caused by an excessive systemic inflammatory response triggered by precipitants that are clinically apparent (e.g., proven microbial infection with sepsis, severe alcohol-related hepatitis) or not. Since the description of ACLF, some important studies have suggested that patients with ACLF may benefit from liver transplantation and because of this, should be urgently stabilised for transplantation by receiving appropriate treatment of identified precipitants, and full general management, including support of organ systems in the intensive care unit (ICU). The objective of the present Clinical Practice Guidelines is to provide recommendations to help clinicians recognise ACLF, make triage decisions (ICU vs. no ICU), identify and manage acute precipitants, identify organ systems that require support or replacement, define potential criteria for futility of intensive care, and identify potential indications for liver transplantation. Based on an in-depth review of the relevant literature, we provide recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence-Based Medicine system and categorised as 'weak' or 'strong'. We aim to provide the best available evidence to aid the clinical decision-making process in the management of patients with ACLF.
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6
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Pimienta M, Tien C, Terrault NA. Prospective clinical trials and novel therapies in the medical management of severe alcohol-associated hepatitis. Clin Liver Dis (Hoboken) 2022; 20:202-208. [PMID: 36523864 PMCID: PMC9745256 DOI: 10.1002/cld.1265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/07/2022] [Accepted: 08/16/2022] [Indexed: 12/15/2022] Open
Abstract
Content available: Author Interview and Audio Recording.
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Affiliation(s)
- Michael Pimienta
- Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordCaliforniaUSA,Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Christine Tien
- Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Norah A. Terrault
- Keck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA,Division of Gastrointestinal and Liver DiseasesUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
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Nath P, Anand AC. Extrahepatic Manifestations in Alcoholic Liver Disease. J Clin Exp Hepatol 2022; 12:1371-1383. [PMID: 36157144 PMCID: PMC9499846 DOI: 10.1016/j.jceh.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/20/2022] [Indexed: 12/12/2022] Open
Abstract
Though liver is the most commonly affected organ in patients with chronic and excessive intake of alcohol, no organ is immune to toxic effects of alcohol and patients with alcohol-related liver disease (ALD) can suffer from a wide list of extrahepatic manifestations involving gastrointestinal tract, central and peripheral nervous systems, cardio vascular system, musculo-skeletal system, disruption of nutritional status, endocrinological abnormalities, hematological abnormalities and immune dysfunction. These extrahepatic organ involvements are usually overlooked by hepatologists and physicians who are mostly focused on managing life threatening complications of ALD. As a result, there is delayed diagnosis, delay in the initiation of appropriate treatment and late referral to other specialists. Some of these manifestations are of utmost clinical importance (e.g. delirium tremans and Wernicke's encephalopathy) because an early diagnosis and treatment can lead to full recovery while delayed or no treatment can result in death. On the other hand, several extrahepatic manifestations are of prognostic significance (such as alcoholic cardiomyopathy and malignancies) in which there is an increased risk of morbidity and mortality. Hence, a clear understanding and awareness of the extrahepatic manifestations of ALD is quintessential for proper management of these patients.
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Key Words
- ACE, Angiotensin-Converting-Enzyme
- ALD, Alcohol related Liver Disease
- AUD, Alcohol Use Disorder
- GAVE, Gastric Antral Vascular Ectasia
- GERD, Gastro-Esophageal Reflux Disease
- HCC, Hepatocellular Carcinoma
- HIV, Human Immunodeficiency Virus
- IARC, International Agency for Research on Cancer
- IL, Interleukin
- NERD, Non-Erosive Reflux Disease
- PPI, Proton Pump Inhibitors
- TNF, Tumour Necrosis Factor
- UGI, Upper Gastrointestinal
- WHO, World Health Organization
- alcohol use disorder
- alcohol withdrawal syndrome
- alcoholic cardiomyopathy
- alcoholic liver disease
- alcoholic myopathy
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Affiliation(s)
- Preetam Nath
- Department of Gastroenterology & Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, 751024, India
| | - Anil C. Anand
- Department of Gastroenterology & Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, 751024, India
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Neuman MG, Seitz HK, Teschke R, Malnick S, Johnson-Davis KL, Cohen LB, German A, Hohmann N, Moreira B, Moussa G, Opris M. Molecular, Viral and Clinical Features of Alcohol- and Non-Alcohol-Induced Liver Injury. Curr Issues Mol Biol 2022; 44:1294-1315. [PMID: 35723310 PMCID: PMC8947098 DOI: 10.3390/cimb44030087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/06/2022] [Accepted: 03/14/2022] [Indexed: 01/08/2023] Open
Abstract
Hepatic cells are sensitive to internal and external signals. Ethanol is one of the oldest and most widely used drugs in the world. The focus on the mechanistic engine of the alcohol-induced injury has been in the liver, which is responsible for the pathways of alcohol metabolism. Ethanol undergoes a phase I type of reaction, mainly catalyzed by the cytoplasmic enzyme, alcohol dehydrogenase (ADH), and by the microsomal ethanol-oxidizing system (MEOS). Reactive oxygen species (ROS) generated by cytochrome (CYP) 2E1 activity and MEOS contribute to ethanol-induced toxicity. We aimed to: (1) Describe the cellular, pathophysiological and clinical effects of alcohol misuse on the liver; (2) Select the biomarkers and analytical methods utilized by the clinical laboratory to assess alcohol exposure; (3) Provide therapeutic ideas to prevent/reduce alcohol-induced liver injury; (4) Provide up-to-date knowledge regarding the Corona virus and its affect on the liver; (5) Link rare diseases with alcohol consumption. The current review contributes to risk identification of patients with alcoholic, as well as non-alcoholic, liver disease and metabolic syndrome. Additional prevalence of ethnic, genetic, and viral vulnerabilities are presented.
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Affiliation(s)
- Manuela G. Neuman
- In Vitro Drug Safety and Biotechnology and the Department of Pharmacology and Toxicology, Temerity Faculty of Medicine, University of Toronto, Toronto, ON M5G 1L5, Canada; (G.M.); (M.O.)
- Correspondence:
| | - Helmut K. Seitz
- Centre of Liver and Alcohol Diseases, Ethianum Clinic and Department of Clinical Pharmacology and Pharmacoepidemiology, Faculty of Medicine, University of Heidelberg, 69115 Heidelberg, Germany; (H.K.S.); (N.H.); (B.M.)
| | - Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Hanau, Academic Teaching Hospital of the Medical Faculty, Goethe University Frankfurt/Main, 60323 Frankfurt, Germany;
| | - Stephen Malnick
- Department of Internal Medicine C. Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Rehovot 76100, Israel; (S.M.); (A.G.)
| | - Kamisha L. Johnson-Davis
- Department of Pathology, University of Utah Health Sciences Centre and Division of Toxicology, ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT 84115, USA;
| | - Lawrence B. Cohen
- Division of Gastroenterology, Sunnybrook Health Sciences Centre and Department of Medicine, Temerity Faculty of Medicine, University of Toronto, Toronto, ON M4N 3N5, Canada;
| | - Anit German
- Department of Internal Medicine C. Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Rehovot 76100, Israel; (S.M.); (A.G.)
| | - Nicolas Hohmann
- Centre of Liver and Alcohol Diseases, Ethianum Clinic and Department of Clinical Pharmacology and Pharmacoepidemiology, Faculty of Medicine, University of Heidelberg, 69115 Heidelberg, Germany; (H.K.S.); (N.H.); (B.M.)
| | - Bernhardo Moreira
- Centre of Liver and Alcohol Diseases, Ethianum Clinic and Department of Clinical Pharmacology and Pharmacoepidemiology, Faculty of Medicine, University of Heidelberg, 69115 Heidelberg, Germany; (H.K.S.); (N.H.); (B.M.)
| | - George Moussa
- In Vitro Drug Safety and Biotechnology and the Department of Pharmacology and Toxicology, Temerity Faculty of Medicine, University of Toronto, Toronto, ON M5G 1L5, Canada; (G.M.); (M.O.)
| | - Mihai Opris
- In Vitro Drug Safety and Biotechnology and the Department of Pharmacology and Toxicology, Temerity Faculty of Medicine, University of Toronto, Toronto, ON M5G 1L5, Canada; (G.M.); (M.O.)
- Family Medicine Clinic CAR, 010362 Bucharest, Romania
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Wang R, Huang X, Zhou T, Li Y, Ding M, Xu H, Gao Y. Safety and Feasibility of Early Oral Nutrition after Endoscopic Treatment for Patients with Liver Cirrhosis: A Historical-prospective, Comparative-Effectiveness Study. JPEN J Parenter Enteral Nutr 2022; 46:1660-1670. [PMID: 35040175 DOI: 10.1002/jpen.2328] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/02/2021] [Accepted: 01/03/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND This study aimed to evaluate the safety and efficacy of early oral nutrition (EON) after endoscopic treatment compared with parenteral nutrition (PN) for patients with gastroesophageal variceal bleeding varices as cirrhotic complications. METHODS This historical-prospective study enrolled patients from Qilu Hospital of Shandong University in China with gastroesophageal varices as cirrhotic complications and undergoing endoscopic therapy. A total of 197 patients who fasted for 4 h after treatment were prospectively enrolled as the oral nutrition group whereas those who fasted for more than 48 h were retrospectively matched in a ratio of 1:1 as the parenteral nutrition group. The primary endpoint was variceal re-bleeding, whereas the secondary endpoints were mortality and adverse events during the 42-day follow-up. Hospitalisation duration and expenses, levels of inflammatory factors, defecation time, and the satisfaction of patients were evaluated. RESULTS During the 42-day follow-up, no significant difference was observed in the rate of variceal re-bleeding (P = 0.586) and morality (P = 1.000) between the oral nutrition group and the parenteral nutrition group. However, the average days of hospitalisation (P < 0.001) and expenses (P < 0.001) were significantly decreased in the oral nutrition group. Furthermore, C-reactive protein lever (P = 0.002) and defecation time (P < 0.001) were lower, whereas the satisfaction rate was higher (P < 0.001) in the oral nutrition group than those in the parenteral nutrition group. Linear regression analysis showed that tissue adhesive dosage was related to diet time (P = 0.038, 95% CI: 0,135-4.516). CONCLUSIONS EON was proven to be safe, feasible, and hence, recommended after endoscopic treatment in patients with cirrhosis. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Renren Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan City, Shandong Province, People's Republic of China
| | - Xiaoli Huang
- Department of Nutrition, Qilu Hospital of Shandong University, Jinan City, Shandong Province, People's Republic of China
| | - Tao Zhou
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan City, Shandong Province, People's Republic of China
| | - Yueyue Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan City, Shandong Province, People's Republic of China
| | - Mengmeng Ding
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan City, Shandong Province, People's Republic of China
| | - Huawei Xu
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan City, Shandong Province, People's Republic of China
| | - Yanjing Gao
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan City, Shandong Province, People's Republic of China
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Ting PS, Gurakar A, Wheatley J, Chander G, Cameron AM, Chen PH. Approaching Alcohol Use Disorder After Liver Transplantation for Acute Alcoholic Hepatitis. Clin Liver Dis 2021; 25:645-671. [PMID: 34229846 PMCID: PMC8264137 DOI: 10.1016/j.cld.2021.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Severe alcoholic hepatitis portends a high risk of mortality without liver transplantation. Transplant outcomes in patients with severe alcoholic hepatitis exhibit a strong inverse association with post-transplant alcohol relapse. The ingredients most central to ameliorating alcohol relapse risk may include destigmatized post-transplant alcohol monitoring, a nonpunitive clinician-patient partnership, and multimodal therapies to maintain abstinence and mitigate high-risk drinking. We here review the core principles of post-liver transplant management specific to alcohol use disorder.
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Affiliation(s)
- Peng-Sheng Ting
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 431, Baltimore, MD 21287, USA
| | - Ahmet Gurakar
- Liver Transplant, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross Research Building, Suite 918, Baltimore, MD 21205, USA.
| | - Jason Wheatley
- Department of Social Work, Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie Suite 100, Baltimore, MD 21287, USA
| | - Geetanjali Chander
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Room 8047A, Baltimore, MD 21287, USA
| | - Andrew M Cameron
- Division of Liver Transplant Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 765, Baltimore, MD 21205, USA
| | - Po-Hung Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 429, Baltimore, MD 21287, USA
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11
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Song DS. [Medical Treatment of Alcoholic Liver Disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 76:65-70. [PMID: 32839368 DOI: 10.4166/kjg.2020.76.2.65] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 12/13/2022]
Abstract
Alcoholic liver disease is a major cause of liver disease that results in significant morbidity and mortality in Korea. Abstinence is the most important strategy to prevent disease progression. Corticosteroids improve the one-month survival in patients with severe alcoholic hepatitis, but it was not effective on long-term survival. An N-acetylcysteine treatment combined with corticosteroids may provide a short-term survival benefit than corticosteroids alone. Pentoxifylline is unlikely to affect short-term survival. Hence, studies on new therapies, such as granulocyte colony-stimulating factor and fecal microbiota transplantation, are ongoing. This paper briefly reviews the current knowledge of the medical treatment of alcoholic liver disease.
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Affiliation(s)
- Do Seon Song
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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12
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Bhavsar-Burke I, Jansson-Knodell CL, Gilmore AC, Crabb DW. Review article: the role of nutrition in alcohol-associated liver disease. Aliment Pharmacol Ther 2021; 53:1268-1276. [PMID: 33896017 DOI: 10.1111/apt.16380] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/05/2021] [Accepted: 04/07/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Malnutrition is a commonly encountered issue in patients with alcohol-associated liver disease. The role of nutritional supplementation in the management of alcohol-associated liver disease is integral to patient outcomes-it has been shown to decrease rates of hepatic encephalopathy, improve outcomes post-liver transplant, reduce 90-day hospital readmissions and lower mortality. Despite these benefits, many studies have shown nutritional support to be an underutilised tool in the care of patients with alcohol-associated liver disease. AIMS To review the epidemiology, pathophysiology, recommendations for nutritional assessment and supplementation, as well as future directions for research of the relationship between nutrition and alcohol-associated liver disease. METHODS A literature search was conducted via PubMed using MeSH terms to inform this narrative review. RESULTS Decreased dietary intake, socioeconomic status, impaired absorption of nutrients and increased free radical species are implicated in the pathophysiology of malnutrition in alcohol-associated liver disease. CONCLUSIONS Malnutrition is common in alcohol-associated liver disease, and physicians should be aware of its association with poor clinical outcomes. Routine nutritional assessment, involvement of a dietician and nutritional supplementation are recommended to improve clinical outcomes in patients with alcohol-associated liver disease.
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Affiliation(s)
- Indira Bhavsar-Burke
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis, IN, USA
| | - Claire L Jansson-Knodell
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis, IN, USA
| | - Ashley C Gilmore
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis, IN, USA
| | - David W Crabb
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis, IN, USA
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13
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Yirui L, Yin W, Juan L, Yanpei C. The clinical effect of early enteral nutrition in liver-transplanted patients: a systematic review and meta-analysis. Clin Res Hepatol Gastroenterol 2021; 45:101594. [PMID: 33887541 DOI: 10.1016/j.clinre.2020.101594] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Appropriate nutritional support is critical for patients undergoing liver transplantation (LT). Early enteral nutrition (EEN) has been considered effective in critically ill patients. However, the clinical effect of EEN on liver-transplanted patients is unclear. AIM To evaluate the clinical effect of early enteral nutrition in patients receiving a liver transplant. METHODS A systematic search was performed on the Cochrane Library, PubMed, CINAHL, EMBASE, Web of Science, WanFang database, Chinese Biomedical Literature Database and China National Knowledge Infrastructure to collect relevant studies up to January, 2020. The results of these studies were pooled to calculate relative risk and mean differences with 95% confidence intervals for dichotomous data and continuous data. All statistical analysis was carried out by Review Manager 5.3. RESULTS 9 RCTs and 10 cohort studies with 1300 patients were included in this meta-analysis. Compared with TPN, EEN reduced postoperative infection rates, ICU hours, length of hospitalization, and the duration of bowel ventilation as well as strengthening the nutritional status and liver function of LT patients. There is no difference in mortality rates, blood glucose levels or gastrointestinal complications. Compared to TPN, the combined EN + PN method more effectively prevented infection. CONCLUSION For patients undergoing liver transplantation, early enteral nutrition with or without combination may considered as a better nutritional therapy than total parenteral nutrition.
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Affiliation(s)
- Li Yirui
- School of Nursing, Fudan University, Shanghai 200032, China
| | - Wei Yin
- Nursing Department, Huashan Hospital Affiliated to Fudan University, No.12 Urumqi Middle Road, Jing'an District, Shanghai 200040, China
| | - Li Juan
- Nursing Department, Huashan Hospital Affiliated to Fudan University, No.12 Urumqi Middle Road, Jing'an District, Shanghai 200040, China.
| | - Cao Yanpei
- Nursing Department, Huashan Hospital Affiliated to Fudan University, No.12 Urumqi Middle Road, Jing'an District, Shanghai 200040, China.
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14
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Sciarrone SS, Zanetto A, Russo FP, Germani G, Gambato M, Battistella S, Pellone M, Shalaby S, Burra P, Senzolo M. Malnourished cirrhotic patient: what should we do? Minerva Gastroenterol (Torino) 2021; 67:11-22. [PMID: 33784807 DOI: 10.23736/s2724-5985.20.02776-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Malnutrition and sarcopenia have a high prevalence in cirrhotic patients. Frailty generally overlaps with malnutrition and sarcopenia in cirrhosis, leading to increased morbidity and mortality. Rapid nutritional screening assessment should be performed in all patients with cirrhosis, and more specific tests for sarcopenia should be performed in those at high risk. The pathogenesis of malnutrition in cirrhosis is complex and multifactorial and it is not just due to reduction in protein and calorie intake. Nutritional management in malnourished patients with cirrhosis should be undertaken by a multidisciplinary team to achieve adequate protein/calorie intake. While the role of branched-chained amino acids remains somewhat contentious in achieving a global benefit of decreasing mortality- and liver-related events, these latter and vitamin supplements, are recommended for those with advanced liver disease. Novel strategies to reverse sarcopenia such as hormone supplementation, long-term ammonia-lowering agents and myostatin antagonists, are currently under investigation. Malnutrition, sarcopenia and frailty are unique, inter-related and multidimensional problems in cirrhosis which require special attention, prompt assessment and appropriate management as they significantly impact morbidity and mortality.
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Affiliation(s)
- Salvatore S Sciarrone
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Alberto Zanetto
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Francesco P Russo
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Giacomo Germani
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Martina Gambato
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Sara Battistella
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Monica Pellone
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Sarah Shalaby
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Patrizia Burra
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Marco Senzolo
- Unit of Multivisceral Trasplants, Department of Surgery Oncology and Gastroenterology, Padua University Hospital, Padua, Italy -
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15
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Puri P, Dhiman RK, Taneja S, Tandon P, Merli M, Anand AC, Arora A, Acharya SK, Benjamin J, Chawla YK, Dadhich S, Duseja A, Eapan C, Goel A, Kalra N, Kapoor D, Kumar A, Madan K, Nagral A, Pandey G, Rao PN, Saigal S, Saraf N, Saraswat VA, Saraya A, Sarin SK, Sharma P, Shalimar, Shukla A, Sidhu SS, Singh N, Singh SP, Srivastava A, Wadhawan M. Nutrition in Chronic Liver Disease: Consensus Statement of the Indian National Association for Study of the Liver. J Clin Exp Hepatol 2021; 11:97-143. [PMID: 33679050 PMCID: PMC7897902 DOI: 10.1016/j.jceh.2020.09.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023] Open
Abstract
Malnutrition and sarcopenia are common in patients with chronic liver disease and are associated with increased risk of decompensation, infections, wait-list mortality and poorer outcomes after liver transplantation. Assessment of nutritional status and management of malnutrition are therefore essential to improve outcomes in patients with chronic liver disease. This consensus statement of the Indian National Association for Study of the Liver provides a comprehensive review of nutrition in chronic liver disease and gives recommendations for nutritional screening and treatment in specific clinical scenarios of malnutrition in cirrhosis in adults as well as children with chronic liver disease and metabolic disorders.
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Key Words
- ACLF, acute on chronic liver failure
- ASM, appendicular skeletal muscle mass
- BCAA, branched chain amino acids
- BIA, bioimpedance analysis
- BMD, bone mineral densitometry
- BMI, body mass index
- CLD, chronic liver disease
- CS, corn-starch
- CT, computed tomography
- CTP, Child–Turcotte–Pugh
- DEXA, dual-energy X-ray absorptiometry
- EASL, European Association for the Study of the Liver
- ESPEN, European society for Clinical Nutrition and Metabolism
- GSD, glycogen storage disease
- HGS, hand-grip strength
- IBW, ideal body weight
- IEM, inborn error of metabolism
- INASL, Indian National Association for Study of the Liver
- L3, third lumbar
- LFI, Liver Frailty Index
- MCT, medium-chain triglyceride
- MELD, model for end-stage liver disease
- MLD, metabolic liver disease
- MRI, magnetic resonance imaging
- RDA, recommended daily allowance
- REE, NASH
- RFH-NPT, Royal Free Hospital-Nutritional Prioritizing Tool
- SMI, skeletal muscle index
- Sarcopenia
- TEE, total energy expenditure
- chronic liver disease
- cirrhosis
- malnutrition
- non-alcoholic liver disease, resting energy expenditure
- nutrition
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Affiliation(s)
- Pankaj Puri
- Fortis Escorts Liver & Digestive Diseases Institute, New Delhi, 110025, India
| | - Radha K. Dhiman
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, 00185, Italy
| | - Anil C. Anand
- Kalinga Institute of Medical Sciences, Bhubhaneswar, 751024, Odisha, India
| | - Anil Arora
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences of Sir Ganga Ram Hospital, New Delhi, 110060, India
| | - Subrat K. Acharya
- Fortis Escorts Liver & Digestive Diseases Institute, New Delhi, 110025, India
| | - Jaya Benjamin
- Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, 110070, India
| | - Yogesh K. Chawla
- Kalinga Institute of Medical Sciences, Bhubhaneswar, 751024, Odisha, India
| | - Sunil Dadhich
- Department of Gastroenterology SN Medical College, Jodhpur, 342003, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - C.E. Eapan
- Department of Gastroenterology, Christian Medical College, Vellore, 632004, India
| | - Amit Goel
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Naveen Kalra
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Dharmesh Kapoor
- Department of Gastroenterology, Global Hospital, Hyderabad, 500004, India
| | - Ashish Kumar
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences of Sir Ganga Ram Hospital, New Delhi, 110060, India
| | - Kaushal Madan
- Max Smart Super Speciality Hospital, New Delhi, India
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital, Mumbai, 400026, India
| | - Gaurav Pandey
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Padaki N. Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, 500082, India
| | - Sanjiv Saigal
- Department of Hepatology, Medanta Hospital, Gurugram, 122001, India
| | - Neeraj Saraf
- Department of Hepatology, Medanta Hospital, Gurugram, 122001, India
| | - Vivek A. Saraswat
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110016, India
| | - Shiv K. Sarin
- Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, 110070, India
| | - Praveen Sharma
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences of Sir Ganga Ram Hospital, New Delhi, 110060, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110016, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GSMC & KEM Hospital, Mumbai, 400022, India
| | - Sandeep S. Sidhu
- Department of Gastroenterology, SPS Hospital, Ludhiana, 141001, India
| | - Namrata Singh
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110016, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, 753007, India
| | - Anshu Srivastava
- Department of Hepatobiliary Sciences, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Manav Wadhawan
- Institute of Liver & Digestive Diseases, BL Kapur Memorial Hospital, New Delhi, 110005, India
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16
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Dinani A, Khan A, Dieterich D. Emerging prevalence of fatty liver disease in HIV. Future Virol 2021. [DOI: 10.2217/fvl-2020-0184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Fatty liver disease is a growing concern in people living with HIV, the main drivers are alcoholic liver disease and nonalcoholic fatty liver disease. It has shown to negatively impact HIV care continuum and result in notable non-HIV related morbidity and mortality. With the advancement in antiretroviral therapy and effective direct acting antivirals, fatty liver disease is surfacing as the next big challenge in this population like that observed in the general population. This review article summarizes the gravity of these two common diseases in HIV-infected people and aims to sheds light on an unmet need to develop effective methods to identify, screen and manage fatty liver disease in this unique population.
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Affiliation(s)
- Amreen Dinani
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Ali Khan
- Department of Internal Medicine, Icahn School of Medicine, Mount Sinai West, New York, NY 10019, USA
| | - Douglas Dieterich
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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17
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Bager P, Olesen L, Baltzer RL, Borre M, Aagaard NK. Equal efficacy of gastric and jejunal tube feeding in liver cirrhosis and/or alcoholic hepatitis: a randomised controlled study. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2020; 29:1148-1154. [PMID: 33180609 DOI: 10.12968/bjon.2020.29.20.1148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND AND AIM Malnutrition and muscle mass loss are complications in liver cirrhosis and alcoholic hepatitis (AH). Hospitalised patients who do not meet nutritional requirements are recommended to be fed enterally or parenterally, but no guidelines recommend a specific type of tube. This study aimed to compare the efficacy of jejunal versus gastric feeding. METHOD 40 inpatients with liver cirrhosis and/or AH, a nutritional risk score more than 2 and a reduced daily energy intake were included. Half were randomised to nasogastric (NG) and half to nasojejunal (NJ) tube feeding. All received Peptamen AF as a supplement to oral intake. Participants were followed up until discharge or death. FINDINGS The study evaluated the data for 33 patients for 7 days after tube insertion. Mean daily energy intake for 7 days was 6509 kJ (NG) vs 6605kJ (NJ) (P=0.90). Tubes accidently removed by patients: once (n=16); twice (n=9); three times (n=6), with no differences between NG and NJ. CONCLUSION There were no significant differences in total nutritional intake between early NG feeding and early NJ feeding 7 days after tube insertion. The number of tube replacements was similar in both groups. Choice of tubes for patients with severe liver disease will depend on individual patient characteristics and needs and local facilities.
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Affiliation(s)
- Palle Bager
- Clinical Nurse Specialist/Senior Researcher, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | - Lene Olesen
- Liver Nurse, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | - Rikke L Baltzer
- Liver Nurse, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | - Mette Borre
- Dietitian, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | - Niels K Aagaard
- Consultant, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
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18
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Bischoff SC, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, Plauth M. ESPEN practical guideline: Clinical nutrition in liver disease. Clin Nutr 2020; 39:3533-3562. [PMID: 33213977 DOI: 10.1016/j.clnu.2020.09.001] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Practical guideline is based on the current scientific ESPEN guideline on Clinical Nutrition in Liver Disease. METHODS It has been shortened and transformed into flow charts for easier use in clinical practice. The guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with chronic liver disease. RESULTS A total of 103 statements and recommendations are presented with short commentaries for the nutritional and metabolic management of patients with (i) acute liver failure, (ii) alcoholic steatohepatitis, (iii) non-alcoholic fatty liver disease, (iv) liver cirrhosis, and (v) liver surgery/transplantation. The disease-related recommendations are preceded by general recommendations on the diagnostics of nutritional status in liver patients and on liver complications associated with medical nutrition. CONCLUSION This practical guideline gives guidance to health care providers involved in the management of liver disease to offer optimal nutritional care.
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Affiliation(s)
- Stephan C Bischoff
- Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany.
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Lindsay D Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Tatjana Schütz
- IFB Adiposity Diseases, Leipzig University Medical Centre, Leipzig, Germany
| | - Mathias Plauth
- Department of Internal Medicine, Municipal Hospital of Dessau, Dessau, Germany
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19
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Kamran U, Towey J, Khanna A, Chauhan A, Rajoriya N, Holt A. Nutrition in alcohol-related liver disease: Physiopathology and management. World J Gastroenterol 2020; 26:2916-2930. [PMID: 32587439 PMCID: PMC7304106 DOI: 10.3748/wjg.v26.i22.2916] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/08/2020] [Accepted: 05/21/2020] [Indexed: 02/06/2023] Open
Abstract
Malnutrition encompassing both macro- and micro-nutrient deficiency, remains one of the most frequent complications of alcohol-related liver disease (ArLD). Protein-energy malnutrition can cause significant complications including sarcopenia, frailty and immunodepression in cirrhotic patients. Malnutrition reduces patient’s survival and negatively affects the quality of life of individuals with ArLD. Moreover, nutritional deficit increases the likelihood of hepatic decompensation in cirrhosis. Prompt recognition of at-risk individuals, early diagnosis and treatment of malnutrition remains a key component of ArLD management. In this review, we describe the pathophysiology of malnutrition in ArLD, review the screening tools available for nutritional assessment and discuss nutritional management strategies relevant to the different stages of ArLD, ranging from acute alcoholic hepatitis through to decompensated end stage liver disease.
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Affiliation(s)
- Umair Kamran
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, United Kingdom
| | - Jennifer Towey
- Department of Dietetics, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, United Kingdom
| | - Amardeep Khanna
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, United Kingdom
| | - Abhishek Chauhan
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, United Kingdom
- Centre for Liver Research, Institute of Immunology and Inflammation, and National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, The Medical School, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, United Kingdom
| | - Andrew Holt
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, United Kingdom
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20
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Crabb DW, Im GY, Szabo G, Mellinger JL, Lucey MR. Diagnosis and Treatment of Alcohol-Associated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases. Hepatology 2020; 71:306-333. [PMID: 31314133 DOI: 10.1002/hep.30866] [Citation(s) in RCA: 415] [Impact Index Per Article: 103.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 12/12/2022]
Affiliation(s)
- David W Crabb
- Indiana University School of Medicine, Indianapolis, IN
| | - Gene Y Im
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gyongyi Szabo
- University of Massachusetts Medical School, Worcester, MA
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21
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Plauth M, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, Bischoff SC. ESPEN guideline on clinical nutrition in liver disease. Clin Nutr 2019; 38:485-521. [PMID: 30712783 DOI: 10.1016/j.clnu.2018.12.022] [Citation(s) in RCA: 322] [Impact Index Per Article: 64.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 02/06/2023]
Abstract
This update of evidence-based guidelines (GL) aims to translate current evidence and expert opinion into recommendations for multidisciplinary teams responsible for the optimal nutritional and metabolic management of adult patients with liver disease. The GL was commissioned and financially supported by ESPEN. Members of the guideline group were selected by ESPEN. We searched for meta-analyses, systematic reviews and single clinical trials based on clinical questions according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing the SIGN method. A total of 85 recommendations were made for the nutritional and metabolic management of patients with acute liver failure, severe alcoholic steatohepatitis, non-alcoholic fatty liver disease, liver cirrhosis, liver surgery and transplantation as well as nutrition associated liver injury distinct from fatty liver disease. The recommendations are preceded by statements covering current knowledge of the underlying pathophysiology and pathobiochemistry as well as pertinent methods for the assessment of nutritional status and body composition.
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Affiliation(s)
- Mathias Plauth
- Department of Internal Medicine, Municipal Hospital of Dessau, Dessau, Germany.
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Lindsay D Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Tatjana Schütz
- IFB Adiposity Diseases, Leipzig University Medical Centre, Leipzig, Germany
| | - Stephan C Bischoff
- Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany
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22
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EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol 2019; 70:172-193. [PMID: 30144956 PMCID: PMC6657019 DOI: 10.1016/j.jhep.2018.06.024] [Citation(s) in RCA: 513] [Impact Index Per Article: 102.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 06/28/2018] [Indexed: 12/11/2022]
Abstract
A frequent complication in liver cirrhosis is malnutrition, which is associated with the progression of liver failure, and with a higher rate of complications including infections, hepatic encephalopathy and ascites. In recent years, the rising prevalence of obesity has led to an increase in the number of cirrhosis cases related to non-alcoholic steatohepatitis. Malnutrition, obesity and sarcopenic obesity may worsen the prognosis of patients with liver cirrhosis and lower their survival. Nutritional monitoring and intervention is therefore crucial in chronic liver disease. These Clinical Practice Guidelines review the present knowledge in the field of nutrition in chronic liver disease and promote further research on this topic. Screening, assessment and principles of nutritional management are examined, with recommendations provided in specific settings such as hepatic encephalopathy, cirrhotic patients with bone disease, patients undergoing liver surgery or transplantation and critically ill cirrhotic patients.
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Dasarathy J, McCullough AJ, Dasarathy S. Sarcopenia in Alcoholic Liver Disease: Clinical and Molecular Advances. Alcohol Clin Exp Res 2017; 41:1419-1431. [PMID: 28557005 DOI: 10.1111/acer.13425] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 05/16/2017] [Indexed: 12/18/2022]
Abstract
Despite advances in treatment of alcohol use disorders that focus on increasing abstinence and reducing recidivism, alcoholic liver disease (ALD) is projected to be the major cause of cirrhosis and its complications. Malnutrition is recognized as the most frequent complication in ALD, and despite the high clinical significance, there are no effective therapies to reverse malnutrition in ALD. Malnutrition is a relatively imprecise term, and sarcopenia or skeletal muscle loss, the major component of malnutrition, is primarily responsible for the adverse clinical consequences in patients with liver disease. It is, therefore, critical to define the specific abnormality (sarcopenia) rather than malnutrition in ALD, so that therapies targeting sarcopenia can be developed. Skeletal muscle mass is maintained by a balance between protein synthesis and proteolysis. Both direct effects of ethanol (EtOH) and its metabolites on the skeletal muscle and the consequences of liver disease result in disturbed proteostasis (protein homeostasis) and consequent sarcopenia. Once cirrhosis develops in patients with ALD, abstinence is unlikely to be effective in completely reversing sarcopenia, as other contributors including hyperammonemia, hormonal, and cytokine abnormalities aggravate sarcopenia and maintain a state of anabolic resistance initiated by EtOH. Cirrhosis is also a state of accelerated starvation, with increased gluconeogenesis that requires amino acid diversion from signaling and substrate functions. Novel therapeutic options are being recognized that are likely to supplant the current "deficiency replacement" approach and instead focus on specific molecular perturbations, given the increasing availability of small molecules that can target specific signaling components. Myostatin antagonists, leucine supplementation, and mitochondrial protective agents are currently in various stages of evaluation in preclinical studies to prevent and reverse sarcopenia, in cirrhosis in general, and ALD, specifically. Translation of these data to human studies and clinical application requires priority for allocation of resources.
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Affiliation(s)
| | - Arthur J McCullough
- Department of Gastreoenterology, Hepatology and Pathobiology, Cleveland Clinic, Cleveland, Ohio
| | - Srinivasan Dasarathy
- Department of Gastreoenterology, Hepatology and Pathobiology, Cleveland Clinic, Cleveland, Ohio
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Sarcopenia from mechanism to diagnosis and treatment in liver disease. J Hepatol 2016; 65:1232-1244. [PMID: 27515775 PMCID: PMC5116259 DOI: 10.1016/j.jhep.2016.07.040] [Citation(s) in RCA: 376] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 07/09/2016] [Accepted: 07/25/2016] [Indexed: 12/12/2022]
Abstract
Sarcopenia or loss of skeletal muscle mass is the major component of malnutrition and is a frequent complication in cirrhosis that adversely affects clinical outcomes. These include survival, quality of life, development of other complications and post liver transplantation survival. Radiological image analysis is currently utilized to diagnose sarcopenia in cirrhosis. Nutrient supplementation and physical activity are used to counter sarcopenia but have not been consistently effective because the underlying molecular and metabolic abnormalities persist or are not influenced by these treatments. Even though alterations in food intake, hypermetabolism, alterations in amino acid profiles, endotoxemia, accelerated starvation and decreased mobility may all contribute to sarcopenia in cirrhosis, hyperammonemia has recently gained attention as a possible mediator of the liver-muscle axis. Increased muscle ammonia causes: cataplerosis of α-ketoglutarate, increased transport of leucine in exchange for glutamine, impaired signaling by leucine, increased expression of myostatin (a transforming growth factor beta superfamily member) and an increased phosphorylation of eukaryotic initiation factor 2α. In addition, mitochondrial dysfunction, increased reactive oxygen species that decrease protein synthesis and increased autophagy mediated proteolysis, also play a role. These molecular and metabolic alterations may contribute to the anabolic resistance and inadequate response to nutrient supplementation in cirrhosis. Central and skeletal muscle fatigue contributes to impaired exercise capacity and responses. Use of proteins with low ammoniagenic potential, leucine enriched amino acid supplementation, long-term ammonia lowering strategies and a combination of resistance and endurance exercise to increase muscle mass and function may target the molecular abnormalities in the muscle. Strategies targeting endotoxemia and the gut microbiome need further evaluation.
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Dasarathy S. Nutrition and Alcoholic Liver Disease: Effects of Alcoholism on Nutrition, Effects of Nutrition on Alcoholic Liver Disease, and Nutritional Therapies for Alcoholic Liver Disease. Clin Liver Dis 2016; 20:535-50. [PMID: 27373615 PMCID: PMC4934388 DOI: 10.1016/j.cld.2016.02.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Malnutrition is the most frequent and nearly universal consequence in alcoholic liver disease (ALD) that adversely affects clinical outcomes. Sarcopenia or skeletal muscle loss is the major component of malnutrition in liver disease. There are no effective therapies to prevent or reverse sarcopenia in ALD because the mechanisms are not well understood. Consequences of liver disease including hyperammonemia, hormonal perturbations, endotoxemia and cytokine abnormalities as well as the direct effects of alcohol and its metabolites contribute to sarcopenia in ALD. This article focuses on the prevalence, methods to quantify malnutrition, specifically sarcopenia and potential therapies including novel molecular targeted treatments.
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Affiliation(s)
- Srinivasan Dasarathy
- Departments of Gastroenterology, Hepatology and Pathobiology, Cleveland Clinic, Cleveland, Ohio
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Wu SY, Chen TW, Feng AC, Fan HL, Hsieh CB, Chung KP. Comprehensive risk assessment for early neurologic complications after liver transplantation. World J Gastroenterol 2016; 22:5548-5557. [PMID: 27350733 PMCID: PMC4917615 DOI: 10.3748/wjg.v22.i24.5548] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/26/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine risk factors for early neurologic complications (NCs) after liver transplantation from perspective of recipient, donor, and surgeon.
METHODS: In all, 295 adult recipients were enrolled consecutively between August 2001 and February 2014 from a single medical center in Taiwan. Any NC in the first 30 d post-liver transplantation, and perioperative variables from multiple perspectives were collected and analyzed. The main outcome was a 30-d NC. Generalized additive models were used to detect the non-linear effect of continuous variables on outcome, and to determine cut-off values for categorizing risk. Risk factors were identified using multiple logistic regression analysis.
RESULTS: In all, 288 recipients were included, of whom 142 (49.3%) experienced at least one NC, with encephalopathy being the most common 106 (73%). NCs prolonged hospital stay (35.15 ± 43.80 d vs 20.88 ± 13.58 d, P < 0.001). Liver recipients’ age < 29 or ≥ 60 years, body mass index < 21.6 or > 27.6 kg/m2, Child-Pugh class C, history of preoperative hepatoencephalopathy or mental disorders, day 7 tacrolimus level > 8.9 ng/mL, and postoperative intra-abdominal infection were more likely associated with NCs. Novel risk factors for NCs were donor age < 22 or ≥ 40 years, male-to-male gender matching, graft-recipient weight ratio 0.9%-1.9%, and sequence of transplantation between 31 and 174.
CONCLUSION: NCs post- liver transplantation occurs because of factors related to recipient, donor, and surgeon. Our results provide a basis of risk stratification for surgeon to minimize neurotoxic factors during transplantation.
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Abstract
PURPOSE OF REVIEW Sarcopenia or loss of skeletal muscle mass is the major component of malnutrition and occurs in the majority of patients with liver disease. Lower muscle contractile function also contributes to the adverse consequences of sarcopenia. There are no effective therapies to prevent or reverse sarcopenia in liver disease. This review will discuss the advances in diagnosis, pathogenesis, and treatment options for sarcopenia in liver disease. RECENT FINDINGS Sarcopenia increases mortality and risk of development of other complications of cirrhosis, and worsens postliver transplant outcomes while quality of life is decreased. Unlike other complications of cirrhosis that reverse after liver transplantation, sarcopenia may not improve and actually worsens. Impaired skeletal muscle protein synthesis and increased proteolysis via autophagy contribute to sarcopenia. Hyperammonemia is the best-studied mediator of the liver-muscle axis. Molecular studies show increased expression of myostatin whereas metabolic studies show impaired mitochondrial function and tricarboxylic acid cycle intermediates because of cataplerosis of α-ketoglutarate. Impaired skeletal muscle pyruvate and fatty acid oxidation during hyperammonemia suggest amino acids are diverted to acetyl CoA and potentially aggravate hyperammonemia. Nutritional supplementation is of limited or no benefit and suggests that cirrhosis is a state of anabolic resistance. Exercise may be beneficial but whether it overcomes anabolic resistance is not known. SUMMARY The high clinical significance of sarcopenia is well established. Current approaches to nutritional supplementation have not been effective in reversing sarcopenia because of anabolic resistance. Myostatin antagonists, specific amino acid supplementation, mitochondrial protection, and combination endurance-resistance exercise are potential future therapeutic options.
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Corticosteroids Versus Pentoxifylline for Severe Alcoholic Hepatitis: A Sequential Analysis of Randomized Controlled Trials. J Clin Gastroenterol 2016; 50:871-881. [PMID: 27404293 PMCID: PMC5065367 DOI: 10.1097/mcg.0000000000000585] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Despite the significant morbidity and mortality associated with alcoholic hepatitis, a consensus or generally accepted therapeutic strategy has not yet been reached. The purpose of this analysis was to evaluate the effects of corticosteroids and pentoxifylline on short-term mortality, incidence of hepatorenal syndrome, and sepsis in patients with severe alcoholic hepatitis. MATERIALS AND METHODS We conducted a comprehensive search of the Cochrane library, PUBMED, Scopus, EMBASE, and published proceedings from major hepatology and gastrointestinal meetings from January 1970 to June 2015. All relevant articles irrespective of language, year of publication, type of publication, or publication status were included. Two independent reviewers extracted data and scored publications; a third investigator adjudicated discrepancies. The κ scores were measured to assess the agreement between the 2 initial reviewers. The review and meta-analyses were performed following the recommendations of The Cochrane Collaboration. Conventional meta-analysis and Trial sequential analysis were performed. GRADEpro version 3.6 was used to appraise the quality of epidemiologic evidence. RESULTS A total of 14 studies satisfied inclusion criteria comparing corticosteroids, pentoxifylline, or placebo. Compared with placebo, corticosteroids reduced 28-day mortality (RR=0.53; 95% CI, 0.33-0.84; P=0.006). There was no statistically significant difference in short-term mortality between pentoxifylline and placebo (RR=0.74; 95% CI, 0.46-1.18; P=0.21). Neither corticosteroids nor pentoxifylline impacted the incidence of hepatorenal syndrome or sepsis. Trial sequential analysis confirmed the results of our conventional meta-analysis. CONCLUSIONS AND RELEVANCE Corticosteroids demonstrated a decrease in 28-day mortality in patients with severe alcoholic hepatitis. The evidence from this study is insufficient to support any recommendations regarding the mortality benefit of pentoxifylline in severe alcoholic hepatitis.
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Singh S, Murad MH, Chandar AK, Bongiorno CM, Singal AK, Atkinson SR, Thursz MR, Loomba R, Shah VH. Comparative Effectiveness of Pharmacological Interventions for Severe Alcoholic Hepatitis: A Systematic Review and Network Meta-analysis. Gastroenterology 2015; 149:958-70.e12. [PMID: 26091937 DOI: 10.1053/j.gastro.2015.06.006] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 06/01/2015] [Accepted: 06/02/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Severe alcoholic hepatitis (AH) has high mortality. We assessed the comparative effectiveness of pharmacological interventions for severe AH, through a network meta-analysis combining direct and indirect treatment comparisons. METHODS We conducted a systematic literature review, through February 2015, for randomized controlled trials of adults with severe AH (discriminant function ≥32 and/or hepatic encephalopathy) that compared the efficacy of active pharmacologic interventions (corticosteroids, pentoxifylline, and N-acetylcysteine [NAC], alone or in combination) with each other or placebo, in reducing short-term mortality (primary outcome) and medium-term mortality, acute kidney injury, and/or infections (secondary outcomes). We performed direct and Bayesian network meta-analysis for all treatments, and used Grading of Recommendations Assessment, Development and Evaluation criteria to appraise quality of evidence. RESULTS We included 22 randomized controlled trials (2621 patients) comparing 5 different interventions. In a direct meta-analysis, only corticosteroids decreased risk of short-term mortality. In a network meta-analysis, moderate quality evidence supported the use of corticosteroids alone (relative risk [RR], 0.54; 95% credible interval [CrI], 0.39-0.73) or in combination with pentoxifylline (RR, 0.53; 95% CrI, 0.36-0.78) or NAC (RR, 0.15; 95% CI, 0.05-0.39), to reduce short-term mortality; low quality evidence showed that pentoxifylline also decreased short-term mortality (RR, 0.70; 95% CrI, 0.50-0.97). The addition of NAC, but not pentoxifylline, to corticosteroids may be superior to corticosteroids alone for reducing short-term mortality. No treatment was effective in reducing medium-term mortality. Imprecise estimates and the small number of direct trials lowered the confidence in several comparisons. CONCLUSIONS In patients with severe AH, pentoxifylline and corticosteroids (alone and in combination with pentoxifylline or NAC) can reduce short-term mortality. No treatment decreases risk of medium-term mortality.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California.
| | - Mohammad Hassan Murad
- Knowledge and Evaluation Research Unit, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Apoorva K Chandar
- Division of Gastroenterology and Liver Diseases, Case Western Reserve University, Cleveland, Ohio
| | - Connie M Bongiorno
- Department of Library Services, Mayo Clinic-St. Mary's Hospital Library, Rochester, Minnesota
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, Alabama
| | | | - Mark R Thursz
- Division of Hepatology, Imperial College, London, United Kingdom
| | - Rohit Loomba
- Division of Gastroenterology, Department of Medicine, and Division of Epidemiology, Department of Family and Preventive Medicine, University of California, San Diego, California
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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Fialla AD, Israelsen M, Hamberg O, Krag A, Gluud LL. Nutritional therapy in cirrhosis or alcoholic hepatitis: a systematic review and meta-analysis. Liver Int 2015; 35:2072-8. [PMID: 25645300 DOI: 10.1111/liv.12798] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 01/29/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Patients with cirrhosis and alcoholic hepatitis are often malnourished and have a superimposed stress metabolism, which increases nutritional demands. We performed a systematic review on the effects of nutritional therapy vs. no intervention for patients with cirrhosis or alcoholic hepatitis. METHODS We included trials on nutritional therapy designed to fulfil at least 75% of daily nutritional demand. Authors extracted data in an independent manner. Random-effects and fixed-effect meta-analyses were performed and the results expressed as risk ratios (RR) with 95% confidence intervals (CI). Sequential analyses were performed to evaluate the risk of spurious findings because of random and systematic errors. Subgroup and sensitivity analyses were performed to evaluate the risk of bias and sources of between trial heterogeneity. RESULTS Thirteen randomized controlled trials with 329 allocated to enteral (nine trials) or intravenous (four trials) nutrition and 334 controls. All trials were classed as having a high risk of bias. Random-effects meta-analysis showed that nutritional therapy reduced mortality 0.80 (95% CI, 0.64 to 0.99). The result was not confirmed in sequential analysis. Fixed-effect analysis suggested that nutrition prevented overt hepatic encephalopathy (0.73; 95% CI, 0.55 to 0.96) and infection (0.66; 95% CI, 0.45 to 0.98, respectively), but the results were not confirmed in random-effects analyses. CONCLUSION Our review suggests that nutritional therapy may have beneficial effects on clinical outcomes in cirrhosis and alcoholic hepatitis. High-quality trials are needed to verify our findings.
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Affiliation(s)
- Annette D Fialla
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
| | - Mads Israelsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
| | - Ole Hamberg
- Department of Hepatology, Copenhagen University Hospital Rigshospitalet, Koebenhavn, Denmark
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
| | - Lise Lotte Gluud
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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Abstract
Alcoholic hepatitis (AH) is caused by acute inflammation of the liver in patients that consume excessive amounts of alcohol, usually in a background of cirrhosis. AH can range from mild to severe, life threatening disease with a high rate of short and long-term mortality. Prognostic models have been used to estimate mortality in order to identify those that may benefit from corticosteroids or pentoxifylline. This review focuses on the different prognostic models proposed. While limitations of the prognostic models exist, combining models may be beneficial in order to identify responders to therapy versus non-responders.
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Affiliation(s)
- Erik Rahimi
- Division of Gastroenterology, Hepatology and Nutrition, University of Texas Medical School at Houston, 6431 Fannin Street, MSB 4.234, Houston, TX 77030 USA
| | - Jen-Jung Pan
- Division of Gastroenterology, Hepatology and Nutrition, University of Texas Medical School at Houston, 6431 Fannin Street, MSB 4.234, Houston, TX 77030 USA
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Hasse JM, DiCecco SR. Enteral Nutrition in Chronic Liver Disease: Translating Evidence Into Practice. Nutr Clin Pract 2015; 30:474-87. [PMID: 26113562 DOI: 10.1177/0884533615591058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Malnutrition is prevalent in individuals with chronic liver disease and occurs as a result of inadequate nutrient intake, altered metabolism, and malabsorption. Although limited data show benefits of enteral nutrition (EN) in this population, patients with chronic liver disease often have inadequate oral intake and are potential candidates for EN. The goals of the EN, type and severity of liver disease, and access for EN will influence the decision to initiate EN. This paper summarizes EN studies in patients with liver disease and provides practical tips regarding patient selection, EN access, and EN formula choices. Two case studies illustrate the principles and challenges of providing EN to patients with cirrhosis. The paper concludes with suggested parameters for an EN feeding protocol and recommendations for future research.
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Affiliation(s)
- Jeanette M Hasse
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Sara R DiCecco
- Mayo Clinic Rochester, Department of Dietetics, Rochester, Minnesota
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Abstract
OPINION STATEMENT Hepatic encephalopathy management varies depending on the acuity of liver failure. However, in patients with either acute or chronic liver failure five basic steps in management are critical: stabilization, addressing modifiable precipitating factors, lowering blood ammonia, managing elevated intracranial pressure (ICP) (if present), and managing complications of liver failure that can contribute to encephalopathy, particularly hyponatremia. Because liver failure patients are prone to a variety of other medical problems that can lead to encephalopathy (such as coagulopathy associated intracranial hemorrhage, electrolyte disarray, renal failure, hypotension, hypoglycemia, and infection), a thorough history, physical and neurologic examination is mandated in all encephalopathic liver failure patients. There should be a low threshold for brain imaging in patients with focal neurological deficits given the propensity for spontaneous intracranial hemorrhage. In patients with acute liver failure and high grade encephalopathy, identification of the etiology of acute liver failure is essential to guide treatment and antidote administration, particularly in the case of acetaminophen poisoning. Equally critical is management of elevated ICP in acute liver failure. Intracranial hypertension can be treated with hypertonic saline and/or adjustment of the dialysis bath. Placement of an intracranial monitor to guide ICP therapy is risky because of concomitant coagulopathy and remains controversial. Continuous renal replacement therapy may help lower serum ammonia, treat coexisting uremia, and improve symptoms. Liver transplantation is the definitive treatment for patients with acute liver failure and hepatic encephalopathy. In patients with chronic hepatic encephalopathy, lactulose and rifaxamin remain a mainstay of therapy. In these patients, it is essential to identify reversible causes of hepatic encephalopathy such as increased ammonia production and/or decreased clearance (eg, infection, GI bleed, constipation, hypokalemia, dehydration). Chronic hyponatremia should be managed by gradual sodium correction of no more than 8‒12 meq/L per day to avoid central myelinolysis syndrome. Free water restriction and increased dietary sodium are reasonable, cost effective treatment options. Many emerging therapies, both pharmacologic and interventional, are currently being studied to improve management of hepatic encephalopathy.
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Dasarathy S. Treatment to improve nutrition and functional capacity evaluation in liver transplant candidates. ACTA ACUST UNITED AC 2014; 12:242-55. [PMID: 24691782 DOI: 10.1007/s11938-014-0016-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT Liver transplantation is the definitive therapy for cirrhosis, and malnutrition is the most frequent complication in these patients. Sarcopenia or loss of muscle mass is the major component of malnutrition in cirrhotics and adversely affects their outcome. In addition to the metabolic consequences, functional consequences of sarcopenia include reduced muscle strength and deconditioning. Despite nearly universal occurrence of sarcopenia and its attendant complications, there are no established therapies to prevent or reverse the same. Major reasons for this deficiency include the lack of established standardized definitions or measures to quantify muscle mass, as well as paucity of mechanistic studies or identified molecular targets to develop specific therapeutic interventions. Anthropometric evaluation, bioelectrical impedance analysis, and DEXA scans are relatively imprecise measures of muscle mass, and recent data on imaging measures to determine muscle mass accurately are likely to allow well-defined outcome responses to treatments. Resurgence of interest in the mechanisms of muscle loss in liver disease has been directly related to the rapid advances in the field of muscle biology. Metabolic tracer studies on whole body kinetics have been complemented by direct studies on the skeletal muscle of cirrhotics. Hypermetabolism and anabolic resistance contribute to sarcopenia. Reduced protein synthesis and increased autophagy have been reported in cirrhotic skeletal muscle, while the contribution of the ubiquitin-proteasome pathway is controversial. Increased plasma concentration and skeletal muscle expression of myostatin, a TGFβ superfamily member that causes reduction in muscle mass, have been reported in cirrhosis. Hyperammonemia and TNFα have been reported to increase myostatin expression and may be responsible for sarcopenia in cirrhosis. Nutriceutical interventions with leucine enriched amino acid mixtures, myostatin antagonists and physical activity hold promise as measures to reverse sarcopenia. There is even less data on muscle function and deconditioning in cirrhosis and studies in this area are urgently needed. Even though macronutrient replacement is a major therapeutic goal, micronutrient supplementation, specifically vitamin D, is expected to improve outcomes.
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Affiliation(s)
- Srinivasan Dasarathy
- Lerner Research Institute, NE4 208, 9500 Euclid Avenue, Cleveland, OH, 44195, USA,
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Abstract
PURPOSE OF REVIEW Although there is a well established association between malnutrition and poorer clinical outcomes in patients with liver disease, that fact alone does not prove that improving the malnutrition will improve outcome. The best way to determine if nutritional interventions are effective is to compare them to untreated control groups in well designed and executed randomized clinical trials. RECENT FINDINGS A recent systematic review assessed 37 trials that compared parenteral nutrition, enteral nutrition, or nutritional supplements to no nutritional therapy in patients with a variety of liver diseases. Since the publication of that review, an additional three trials have become available. Whereas all but one of the trials did have methodologic shortcomings that may have allowed the introduction of bias (which usually results in an overestimation of benefit), the trials failed to show much, if any, benefit. In fact, the single trial at low risk of bias found that more deaths occurred in the recipients of the supplements. SUMMARY Although malnutrition may be associated with a poor outcome, the current best evidence indicates that the provision of adjunctive nutritional support (parenteral or enteral nutrition, or nutritional supplements) to patients with a variety of liver diseases (alcoholic hepatitis, cirrhosis, hepatocellular carcinoma, liver surgery, liver transplantation, obstructive jaundice, hepatitis C antiviral treatment) does not improve clinical outcomes.
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Thapaliya S, Runkana A, McMullen MR, Nagy LE, McDonald C, Naga Prasad SV, Dasarathy S. Alcohol-induced autophagy contributes to loss in skeletal muscle mass. Autophagy 2014; 10:677-90. [PMID: 24492484 DOI: 10.4161/auto.27918] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Patients with alcoholic cirrhosis and hepatitis have severe muscle loss. Since ethanol impairs skeletal muscle protein synthesis but does not increase ubiquitin proteasome-mediated proteolysis, we investigated whether alcohol-induced autophagy contributes to muscle loss. Autophagy induction was studied in: A) Human skeletal muscle biopsies from alcoholic cirrhotics and controls, B) Gastrocnemius muscle from ethanol and pair-fed mice, and C) Ethanol-exposed murine C2C12 myotubes, by examining the expression of autophagy markers assessed by immunoblotting and real-time PCR. Expression of autophagy genes and markers were increased in skeletal muscle from humans and ethanol-fed mice, and in myotubes following ethanol exposure. Importantly, pulse-chase experiments showed suppression of myotube proteolysis upon ethanol-treatment with the autophagy inhibitor, 3-methyladenine (3MA) and not by MG132, a proteasome inhibitor. Correspondingly, ethanol-treated C2C12 myotubes stably expressing GFP-LC3B showed increased autophagy flux as measured by accumulation of GFP-LC3B vesicles with confocal microscopy. The ethanol-induced increase in LC3B lipidation was reversed upon knockdown of Atg7, a critical autophagy gene and was associated with reversal of the ethanol-induced decrease in myotube diameter. Consistently, CT image analysis of muscle area in alcoholic cirrhotics was significantly reduced compared with control subjects. In order to determine whether ethanol per se or its metabolic product, acetaldehyde, stimulates autophagy, C2C12 myotubes were treated with ethanol in the presence of the alcohol dehydrogenase inhibitor (4-methylpyrazole) or the acetaldehyde dehydrogenase inhibitor (cyanamide). LC3B lipidation increased with acetaldehyde treatment and increased further with the addition of cyanamide. We conclude that muscle autophagy is increased by ethanol exposure and contributes to sarcopenia.
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Affiliation(s)
| | - Ashok Runkana
- Department of Pathobiology; Cleveland Clinic; Cleveland, OH USA; Department of Internal Medicine; Fairview Hospital; Cleveland, OH USA
| | | | - Laura E Nagy
- Department of Pathobiology; Cleveland Clinic; Cleveland, OH USA; Department of Gastroenterology and Hepatology; Cleveland Clinic; Cleveland, OH USA
| | | | | | - Srinivasan Dasarathy
- Department of Pathobiology; Cleveland Clinic; Cleveland, OH USA; Department of Gastroenterology and Hepatology; Cleveland Clinic; Cleveland, OH USA
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de la Monte SM, Kril JJ. Human alcohol-related neuropathology. Acta Neuropathol 2014; 127:71-90. [PMID: 24370929 DOI: 10.1007/s00401-013-1233-3] [Citation(s) in RCA: 250] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 12/12/2013] [Accepted: 12/13/2013] [Indexed: 02/08/2023]
Abstract
Alcohol-related diseases of the nervous system are caused by excessive exposures to alcohol, with or without co-existing nutritional or vitamin deficiencies. Toxic and metabolic effects of alcohol (ethanol) vary with brain region, age/developmental stage, dose, and duration of exposures. In the mature brain, heavy chronic or binge alcohol exposures can cause severe debilitating diseases of the central and peripheral nervous systems, and skeletal muscle. Most commonly, long-standing heavy alcohol abuse leads to disproportionate loss of cerebral white matter and impairments in executive function. The cerebellum (especially the vermis), cortical-limbic circuits, skeletal muscle, and peripheral nerves are also important targets of chronic alcohol-related metabolic injury and degeneration. Although all cell types within the nervous system are vulnerable to the toxic, metabolic, and degenerative effects of alcohol, astrocytes, oligodendrocytes, and synaptic terminals are major targets, accounting for the white matter atrophy, neural inflammation and toxicity, and impairments in synaptogenesis. Besides chronic degenerative neuropathology, alcoholics are predisposed to develop severe potentially life-threatening acute or subacute symmetrical hemorrhagic injury in the diencephalon and brainstem due to thiamine deficiency, which exerts toxic/metabolic effects on glia, myelin, and the microvasculature. Alcohol also has devastating neurotoxic and teratogenic effects on the developing brain in association with fetal alcohol spectrum disorder/fetal alcohol syndrome. Alcohol impairs function of neurons and glia, disrupting a broad array of functions including neuronal survival, cell migration, and glial cell (astrocytes and oligodendrocytes) differentiation. Further progress is needed to better understand the pathophysiology of this exposure-related constellation of nervous system diseases and better correlate the underlying pathology with in vivo imaging and biochemical lesions.
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Abstract
Alcohol-related diseases of the nervous system are caused by excessive exposures to alcohol, with or without co-existing nutritional or vitamin deficiencies. Toxic and metabolic effects of alcohol (ethanol) vary with brain region, age/developmental stage, dose, and duration of exposures. In the mature brain, heavy chronic or binge alcohol exposures can cause severe debilitating diseases of the central and peripheral nervous systems, and skeletal muscle. Most commonly, long-standing heavy alcohol abuse leads to disproportionate loss of cerebral white matter and impairments in executive function. The cerebellum (especially the vermis), cortical-limbic circuits, skeletal muscle, and peripheral nerves are also important targets of chronic alcohol-related metabolic injury and degeneration. Although all cell types within the nervous system are vulnerable to the toxic, metabolic, and degenerative effects of alcohol, astrocytes, oligodendrocytes, and synaptic terminals are major targets, accounting for the white matter atrophy, neural inflammation and toxicity, and impairments in synaptogenesis. Besides chronic degenerative neuropathology, alcoholics are predisposed to develop severe potentially life-threatening acute or subacute symmetrical hemorrhagic injury in the diencephalon and brainstem due to thiamine deficiency, which exerts toxic/metabolic effects on glia, myelin, and the microvasculature. Alcohol also has devastating neurotoxic and teratogenic effects on the developing brain in association with fetal alcohol spectrum disorder/fetal alcohol syndrome. Alcohol impairs function of neurons and glia, disrupting a broad array of functions including neuronal survival, cell migration, and glial cell (astrocytes and oligodendrocytes) differentiation. Further progress is needed to better understand the pathophysiology of this exposure-related constellation of nervous system diseases and better correlate the underlying pathology with in vivo imaging and biochemical lesions.
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Bemeur C. Neurological complications post-liver transplantation: impact of nutritional status. Metab Brain Dis 2013; 28:293-300. [PMID: 23129292 DOI: 10.1007/s11011-012-9352-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 10/22/2012] [Indexed: 12/11/2022]
Abstract
Nutritional status is significantly altered in patients with end-stage liver disease (cirrhosis). Malnutrition is a common complication of cirrhosis and is known to be associated with a greater risk of post-operative complications and mortality, especially following liver transplantation. Neurological complications occur frequently after transplant and the nature and extent of these complications may relate to nutritional deficits such as protein-calorie malnutrition as well as vitamin and micronutrient deficiencies. A consensus document from the International Society on Hepatic Encephalopathy and Nitrogen metabolism (ISHEN) has been established in order to address these concerns. Careful assessment of nutritional status followed by prompt treatment of nutritional deficits has the potential to impact on transplant outcome and, in particular, on post-transplant neurological disorders in patients with cirrhosis.
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Affiliation(s)
- Chantal Bemeur
- Department of Nutrition, University of Montreal, Montreal, Québec, Canada.
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