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Wong YJ, Abraldes JG. Pharmacologic Treatment of Portal Hypertension. Clin Liver Dis 2024; 28:417-435. [PMID: 38945635 DOI: 10.1016/j.cld.2024.03.002] [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] [Indexed: 07/02/2024]
Abstract
Portal hypertension is the key mechanism driving the transition from compensated to decompensated cirrhosis. In this review, the authors described the pathophysiology of portal hypertension in cirrhosis and the rationale of pharmacologic treatment of portal hypertension. We discussed both etiologic and nonetiologic treatment of portal hypertension and the specific clinical scenarios how nonselective beta-blocker can be used in patients with cirrhosis. Finally, the authors summarized the evidence for emerging alternatives for portal hypertension in patients with cirrhosis.
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Affiliation(s)
- Yu Jun Wong
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada; Liver Unit, Division of Gastroenterology, University of Alberta, 1-38 Zeidler Ledcor Centre, 8540 112 Street Northwest, Edmonton, Alberta T6G 2X8, Canada
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, 1-38 Zeidler Ledcor Centre, 8540 112 Street Northwest, Edmonton, Alberta T6G 2X8, Canada.
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2
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Holeček M. Origin and Roles of Alanine and Glutamine in Gluconeogenesis in the Liver, Kidneys, and Small Intestine under Physiological and Pathological Conditions. Int J Mol Sci 2024; 25:7037. [PMID: 39000145 PMCID: PMC11241752 DOI: 10.3390/ijms25137037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/21/2024] [Accepted: 06/25/2024] [Indexed: 07/16/2024] Open
Abstract
Alanine and glutamine are the principal glucogenic amino acids. Most originate from muscles, where branched-chain amino acids (valine, leucine, and isoleucine) are nitrogen donors and, under exceptional circumstances, a source of carbons for glutamate synthesis. Glutamate is a nitrogen source for alanine synthesis from pyruvate and a substrate for glutamine synthesis by glutamine synthetase. The following differences between alanine and glutamine, which can play a role in their use in gluconeogenesis, are shown: (i) glutamine appearance in circulation is higher than that of alanine; (ii) the conversion to oxaloacetate, the starting substance for glucose synthesis, is an ATP-consuming reaction for alanine, which is energetically beneficial for glutamine; (iii) most alanine carbons, but not glutamine carbons, originate from glucose; and (iv) glutamine acts a substrate for gluconeogenesis in the liver, kidneys, and intestine, whereas alanine does so only in the liver. Alanine plays a significant role during early starvation, exposure to high-fat and high-protein diets, and diabetes. Glutamine plays a dominant role in gluconeogenesis in prolonged starvation, acidosis, liver cirrhosis, and severe illnesses like sepsis and acts as a substrate for alanine synthesis in the small intestine. Interactions among muscles and the liver, kidneys, and intestine ensuring optimal alanine and glutamine supply for gluconeogenesis are suggested.
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Affiliation(s)
- Milan Holeček
- Department of Physiology, Faculty of Medicine, Charles University, 500 03 Hradec Kralove, Czech Republic
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3
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Jiang M, Hua X, Wu M, Wu J, Xu X, Li J, Meng Q. Longitudinal changes in sarcopenia was associated with survival among cirrhotic patients. Front Nutr 2024; 11:1375994. [PMID: 38873566 PMCID: PMC11169581 DOI: 10.3389/fnut.2024.1375994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/15/2024] [Indexed: 06/15/2024] Open
Abstract
Background Sarcopenia is common in patients with liver cirrhosis and is an independent predictor of multiple clinical outcomes. Most studies to date have used a static assessment of sarcopenia. However, there is very limited data evaluating the temporal course of muscle area in cirrhosis. To bridge this gap in clinical studies, we performed a longitudinal analysis to evaluate the impact of changes in sarcopenia for cirrhotic patients. Methods Adult patients with clinically diagnosed liver cirrhosis who underwent at least 2 abdominal computed tomography (CT) scans in the hospital were enrolled. The interval between the two abdominal scans was 6 ± 1 months. Patients were categorized into persistent non-sarcopenia, new-onset sarcopenia, sarcopenia to non-sarcopenia, and persistent sarcopenia based on changes in sarcopenia. Kaplan-Meier method and Log-rank tests were used to separately compare unadjusted survival curves by different statuses of sarcopenia. Cox regression analysis was performed to assess the associations between different states of sarcopenia and overall mortality. The association between persistent non-sarcopenia and new-onset sarcopenia was analyzed by multivariate logistic regression analysis. Results A total of 307 patients were included for analysis. At the second assessment, 10.10% (31/307) patients were new-onset sarcopenia, 27.69% (85/307) with persistent sarcopenia status, while 13.03% (40/307) patients with sarcopenia developed non-sarcopenia and 49.19% (151/307) with persistent non-sarcopenia status. The overall survival rate was significantly lower in the persistent sarcopenia and new-onset sarcopenia than in the non-sarcopenia group and sarcopenia to non-sarcopenia group (p < 0.001). Persistent sarcopenia (HR 5.799, 95%CI 1.563-21.521, p = 0.009) and new onset sarcopenia (HR 5.205, 95%CI 1.482-18.282, p = 0.010) were identified as poor prognostic factors for cirrhotic patients. The etiology of cirrhosis and the initial skeletal muscle mass were independent risk factors for new-onset sarcopenia. Conclusion Sarcopenia is a dynamically changing process in patients with cirrhosis. Persistent and new-onset sarcopenia were independently and robustly associated with overall survival.
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Affiliation(s)
- Minjie Jiang
- Department of Medical Oncology, Beijing Youan Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Hepatology, Beijing, China
| | - Xin Hua
- Department of Clinical Nutrition, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Muchen Wu
- Department of Medical Oncology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Jing Wu
- Department of Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Xu
- Department of Medical Oncology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Juan Li
- Department of Medical Oncology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Qinghua Meng
- Department of Medical Oncology, Beijing Youan Hospital, Capital Medical University, Beijing, China
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4
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Jokinen MJ, Luukkonen PK. Hepatic mitochondrial reductive stress in the pathogenesis and treatment of steatotic liver disease. Trends Pharmacol Sci 2024; 45:319-334. [PMID: 38471991 DOI: 10.1016/j.tips.2024.02.003] [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: 01/26/2024] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/14/2024]
Abstract
Steatotic liver diseases (SLDs) affect one-third of the population, but the pathogenesis underlying these diseases is not well understood, limiting the available treatments. A common factor in SLDs is increased hepatic mitochondrial reductive stress, which occurs as a result of excessive lipid and alcohol metabolism. Recent research has also shown that genetic risk factors contribute to this stress. This review aims to explore how these risk factors increase hepatic mitochondrial reductive stress and how it disrupts hepatic metabolism, leading to SLDs. Additionally, the review will discuss the latest clinical studies on pharmaceutical treatments for SLDs, specifically peroxisome proliferator-activated receptor gamma (PPAR-γ) agonists, thyroid hormone receptor (THR) agonists, acetyl-CoA carboxylase (ACC) inhibitors, and mitochondrial uncouplers. These treatments have a common effect of decreasing hepatic mitochondrial reductive stress, which has been largely overlooked.
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Affiliation(s)
- Mari J Jokinen
- Minerva Foundation Institute for Medical Research, Helsinki, Finland; Department of Internal Medicine, University of Helsinki, Helsinki, Finland; Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Panu K Luukkonen
- Minerva Foundation Institute for Medical Research, Helsinki, Finland; Department of Internal Medicine, University of Helsinki, Helsinki, Finland; Abdominal Center, Helsinki University Hospital, Helsinki, Finland.
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5
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Trinh B, Rasmussen Rinnov A, Winning Iepsen U, Winding Munch G, Munch Winding K, Lauridsen C, Gluud LL, van Hall G, Ellingsgaard H. Glucose turnover at whole-body and skeletal muscle level in response to parenteral nutrition in male patients with alcoholic liver cirrhosis. Clin Nutr ESPEN 2024; 60:240-246. [PMID: 38479917 DOI: 10.1016/j.clnesp.2024.02.013] [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: 12/06/2023] [Revised: 01/21/2024] [Accepted: 02/09/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND & AIMS Cirrhosis is associated with insulin resistance and impaired glucose tolerance, which may be caused by impairments at different tissue levels (liver, skeletal muscle, and/or beta cell). METHODS Here, glucose kinetics at whole-body and skeletal muscle level in patients with cirrhosis (Child-Pugh A and B) were studied during parenteral nutrition using the isotope dilution technique and arteriovenous balance approach across the leg. As opposed to the euglycemic hyperinsulinemic clamp or glucose tolerance tests applied in previous studies, this approach provides a nutrient composition more similar to a normal meal while circumventing any possible portal-systemic shunting, impaired hepatic uptake and incretin effect. RESULTS We confirmed the presence of hepatic and peripheral insulin resistance in our patient population. Endogenous glucose production was less suppressed in response to parenteral nutrition. However, glucose uptake in skeletal muscle was increased. CONCLUSION Our results suggests that in our study participants with cirrhosis, the hepatic and peripheral insulin resistance is compensated for by increased insulin secretion and thus, increased glucose uptake in muscle. Hereby, glucose homeostasis is maintained.
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Affiliation(s)
- Beckey Trinh
- The Centre for Physical Activity Research, Copenhagen University Hospital - Rigshospitalet, Denmark.
| | - Anders Rasmussen Rinnov
- The Centre for Physical Activity Research, Copenhagen University Hospital - Rigshospitalet, Denmark
| | - Ulrik Winning Iepsen
- The Centre for Physical Activity Research, Copenhagen University Hospital - Rigshospitalet, Denmark; Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital - Hvidovre Hospital, Copenhagen, Denmark
| | - Gregers Winding Munch
- The Centre for Physical Activity Research, Copenhagen University Hospital - Rigshospitalet, Denmark
| | - Kamilla Munch Winding
- The Centre for Physical Activity Research, Copenhagen University Hospital - Rigshospitalet, Denmark
| | - Carsten Lauridsen
- Department of Diagnostic Radiology, Copenhagen University Hospital - Rigshospitalet, Denmark; Department of Technology, Copenhagen University College, Denmark
| | - Lise Lotte Gluud
- Gastrounit, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Gerrit van Hall
- Clinical Metabolomics Core Facility, Clinical Biochemistry, Copenhagen University Hospital, Department of Biomedical Sciences, Health & Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Helga Ellingsgaard
- The Centre for Physical Activity Research, Copenhagen University Hospital - Rigshospitalet, Denmark
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Wu M, Wu J, Liu K, Jiang M, Xie F, Yin X, Wu J, Meng Q. LONP1 ameliorates liver injury and improves gluconeogenesis dysfunction in acute-on-chronic liver failure. Chin Med J (Engl) 2024; 137:190-199. [PMID: 38184784 PMCID: PMC10798737 DOI: 10.1097/cm9.0000000000002969] [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: 06/23/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a severe liver disease with complex pathogenesis. Clinical hypoglycemia is common in patients with ACLF and often predicts a worse prognosis. Accumulating evidence suggests that glucose metabolic disturbance, especially gluconeogenesis dysfunction, plays a critical role in the disease progression of ACLF. Lon protease-1 (LONP1) is a novel mediator of energy and glucose metabolism. However, whether gluconeogenesis is a potential mechanism through which LONP1 modulates ACLF remains unknown. METHODS In this study, we collected liver tissues from ACLF patients, established an ACLF mouse model with carbon tetrachloride (CCl 4 ), lipopolysaccharide (LPS), and D-galactose (D-gal), and constructed an in vitro hypoxia and hyperammonemia-triggered hepatocyte injury model. LONP1 overexpression and knockdown adenovirus were used to assess the protective effect of LONP1 on liver injury and gluconeogenesis regulation. Liver histopathology, biochemical index, mitochondrial morphology, cell viability and apoptosis, and the expression and activity of key gluconeogenic enzymes were detected to explore the underlying protective mechanisms of LONP1 in ACLF. RESULTS We found that LONP1 and the expressions of gluconeogenic enzymes were downregulated in clinical ACLF liver tissues. Furthermore, LONP1 overexpression remarkably attenuated liver injury, which was characterized by improved liver histopathological lesions and decreased serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in ACLF mice. Moreover, mitochondrial morphology was improved upon overexpression of LONP1. Meanwhile, the expression and activity of the key gluconeogenic enzymes were restored by LONP1 overexpression. Similarly, the hepatoprotective effect was also observed in the hepatocyte injury model, as evidenced by improved cell viability, reduced cell apoptosis, and improved gluconeogenesis level and activity, while LONP1 knockdown worsened liver injury and gluconeogenesis disorders. CONCLUSION We demonstrated that gluconeogenesis dysfunction exists in ACLF, and LONP1 could ameliorate liver injury and improve gluconeogenic dysfunction, which would provide a promising therapeutic target for patients with ACLF.
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Affiliation(s)
- Muchen Wu
- Department of Liver Disease, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Jing Wu
- Department of Liver Disease, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Kai Liu
- Department of Liver Disease, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
- Beijing Institute of Hepatology, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Minjie Jiang
- Department of Liver Disease, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Fang Xie
- Department of Liver Disease, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
- Beijing Institute of Hepatology, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Xuehong Yin
- Department of Liver Disease, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Jushan Wu
- Department of General Surgery, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
| | - Qinghua Meng
- Department of Liver Disease, Beijing You-An Hospital, Capital Medical University, Beijing 100069, China
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7
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Tan JYT, Cheah CCM, Wang YT, Chang PEJ, Krishnamoorthy TL, Tan HK, Salazar E. Outpatient screening with the Royal Free Hospital-Nutrition Prioritizing Tool for patients with cirrhosis at risk of malnutrition. Nutrition 2023; 114:112139. [PMID: 37450959 DOI: 10.1016/j.nut.2023.112139] [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: 02/24/2023] [Revised: 06/13/2023] [Accepted: 06/17/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES Malnutrition is common among inpatients with cirrhosis. However, data on the prevalence of malnutrition among stable ambulatory patients with cirrhosis is lacking. We sought to investigate the prevalence of patents at risk of malnutrition (ARMN) among ambulatory patients with cirrhosis using the Royal Free Hospital-Nutrition Prioritizing Tool (RFH-NPT) and the Malnutrition Universal Screening Tool (MUST) and compare their correlation to clinical outcomes. METHODS Patients attending an outpatient liver cirrhosis clinic at a tertiary hospital were screened for ARMN using both the RFH-NPT and MUST (defined by a score of ≥2 for either tool). Differences in clinical outcomes after 6 mo were compared. RESULTS There were 134 patients recruited. The RFH-NPT identified more ARMN patients compared with MUST (32.8% versus 8.2%; P < 0.01; Cohen κ, 0.27 [95% CI, 0.12-0.42]; P < 0.001). Fluid overload at recruitment was the only independent predictor of disagreement between the RFH-NPT and MUST (odds ratio [OR], 43.14; 95% CI, 8.70-214.00; P < 0.001). There was a trend toward an increased risk of mortality for ARMN patients by the RFH-NPT (hazard ratio, 3.58; 95% CI, 0.81-15.83; P = 0.06) but not by the MUST (P = 0.62). The incidence of hospital admissions in ARMN patients was higher by the RFH-NPT, with an incidence rate ratio of 13.27 (95% CI, 5.11-43.70; P < 0.001), but not in ARMN patients by the MUST (P = 0.85). Being ARMN by the RFH-NPT was the only independent predictor of hospital admissions (OR, 15.08; 95% CI, 2.47-91.98; P = 0.003). CONCLUSIONS The RFH-NPT identified more ARMN patients when compared with the MUST, especially among patients with fluid overload. Patients at risk of malnutrition were at an increased risk of hospital admissions and possibly death.
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Affiliation(s)
- Jin Y T Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital
| | - Chang C M Cheah
- Department of Gastroenterology and Hepatology, Singapore General Hospital
| | - Yu T Wang
- Department of Gastroenterology and Hepatology, Singapore General Hospital
| | - Pik E J Chang
- Department of Gastroenterology and Hepatology, Singapore General Hospital
| | | | - Hiang K Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital
| | - Ennaliza Salazar
- Department of Gastroenterology and Hepatology, Singapore General Hospital.
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8
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Mishra S, Premkumar M. Nutritional Management of a Liver Transplant Candidate. J Clin Exp Hepatol 2023; 13:878-894. [PMID: 37693267 PMCID: PMC10483011 DOI: 10.1016/j.jceh.2023.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/28/2023] [Indexed: 09/12/2023] Open
Abstract
Nearly two-thirds of patients with cirrhosis suffer from malnutrition resulting from multiple contributory factors such as poor intake, accelerated starvation, catabolic milieu, and anabolic resistance. Nutritional assessment and optimization are integral to adequate management of a liver transplant (LT) candidate. A detailed nutritional assessment should be done at baseline in all potential transplant candidates with periodic reassessments. Sarcopenia is defined as a reduction in muscle mass, function, and/or performance. Skeletal muscle index at 3rd lumbar vertebra determined by computed tomography is the most objective tool to assess muscle mass. Hand-grip strength and gait speed are simple tools to gauge muscle strength and performance, respectively. Sarcopenia, sarcopenic obesity, and myosteatosis portend poor outcomes. Sarcopenia contributes greatly to frailty, which is a syndrome of reduced physiological reserve and impaired response to stressors. Dietary interventions must ensure adequate calorie (35-40 kcal/kg/day) and protein (1.2-1.5 gm/kg/day) intake via multiple frequent meals and late-evening calorie-dense snack. Micronutrient supplementation is essential, keeping in mind the etiology of cirrhosis. Individualized, gradually up-titrated exercise prescription consisting of both aerobic and resistance training of 150 min/week is advisable after appropriate risk assessment. Early initiation of enteral nutrition within 12-24 h of LT is recommended. Data with respect to immune-nutrition, monomeric formulas, and hormone replacement remain conflicting at present. A multidisciplinary team comprising of hepatologists, transplant surgeons, intensivists, dieticians, and physiotherapists is vital to improve overall nutrition and outcomes in this vulnerable group.
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Affiliation(s)
- Saurabh Mishra
- Department of Gastroenterology and Hepatology, Paras Health, Sector-22, Panchkula, Haryana, 134109, India
| | - Madhumita Premkumar
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India
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9
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Leoni L, Valoriani F, Barbieri R, Pambianco M, Vinciguerra M, Sicuro C, Colecchia A, Menozzi R, Ravaioli F. Unlocking the Power of Late-Evening Snacks: Practical Ready-to-Prescribe Chart Menu for Patients with Cirrhosis. Nutrients 2023; 15:3471. [PMID: 37571408 PMCID: PMC10420913 DOI: 10.3390/nu15153471] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 08/13/2023] Open
Abstract
The efficacy of the late-evening snack (LES) has been extensively studied due to the impact of the longest intermeal duration occurring at night in patients with cirrhosis. While actual clinical guidelines on nutrition in chronic liver disease recommend an LES, no specific nutritional compositions have been reported by the European Association for the Study of the Liver (EASL) and the European Society for Clinical Nutrition and Metabolism (ESPEN). Late-evening snacks vary greatly among studies, including natural foods and/or nutritional supplements, yet oral supplements still need to fully meet the LES's nutritional composition. In addition, many hepatologists need to gain experience in nutritional approaches and have access to registered dieticians who can help them manage patients with liver disease. Therefore, this review study aims to summarise evidence regarding using LESs and the mechanisms behind long starvation in patients with cirrhosis. It also provides a practical nutritional guide with several LES options based on common natural foods tailored to special patients' nutritional requirements and geographical backgrounds. In preventing accelerated starvation and related protein malnutrition and sarcopenia in patients with cirrhosis, the nutritional composition of LESs is essential. The proper and straightforward application of the LES's rational nutrition is an advantage to cirrhotic patients and should be carried out by healthcare professionals to enhance the overall liver function and nutritional status of patients with cirrhosis.
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Affiliation(s)
- Laura Leoni
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy; (L.L.); (F.V.); (R.B.); (M.V.); (R.M.)
| | - Filippo Valoriani
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy; (L.L.); (F.V.); (R.B.); (M.V.); (R.M.)
| | - Riccardo Barbieri
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy; (L.L.); (F.V.); (R.B.); (M.V.); (R.M.)
| | - Martina Pambianco
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy; (M.P.); (C.S.); (A.C.)
| | - Martina Vinciguerra
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy; (L.L.); (F.V.); (R.B.); (M.V.); (R.M.)
| | - Chiara Sicuro
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy; (M.P.); (C.S.); (A.C.)
| | - Antonio Colecchia
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy; (M.P.); (C.S.); (A.C.)
| | - Renata Menozzi
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy; (L.L.); (F.V.); (R.B.); (M.V.); (R.M.)
| | - Federico Ravaioli
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy; (M.P.); (C.S.); (A.C.)
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy
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10
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Iepsen UW, Rinnov AR, Munch GW, Rugbjerg M, Winding KM, Lauridsen C, Berg RMG, Pedersen BK, Gluud LL, van Hall G. Skeletal muscle protein turnover responses to parenteral nutrition in patients with alcoholic liver cirrhosis and sarcopenia. Am J Physiol Gastrointest Liver Physiol 2023; 325:G174-G183. [PMID: 37339940 DOI: 10.1152/ajpgi.00242.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/27/2023] [Accepted: 06/13/2023] [Indexed: 06/22/2023]
Abstract
Alcoholic liver cirrhosis (ALC) is accompanied by sarcopenia. The aim of this study was to investigate the acute effects of balanced parenteral nutrition (PN) on skeletal muscle protein turnover in ALC. Eight male patients with ALC and seven age- and sex-matched healthy controls were studied for 3 h of fasting followed by 3 h of intravenous PN (SmofKabiven 1,206 mL: amino acid = 38 g, carbohydrates = 85 g, and fat = 34 g) 4 mL/kg/h. We measured leg blood flow and sampled paired femoral arteriovenous concentrations and quadriceps muscle biopsies while providing a primed continuous infusion of [ring-2d5]-phenylalanine to quantify muscle protein synthesis and breakdown. Patients with ALC exhibited shorter 6-min walking distance (ALC: 487 ± 38 vs. controls: 722 ± 14 m, P < 0.05), lower hand-grip strength (ALC: 34 ± 2 vs. controls: 52 ± 2 kg, P < 0.05), and computed tomography (CT)-verified leg muscle loss (ALC: 5,922 ± 246 vs. controls: 8,110 ± 345 mm2, P < 0.05). Net leg muscle phenylalanine uptake changed from negative (muscle loss) during fasting to positive (muscle gain) in response to PN (ALC: -0.18 ± +0.01 vs. 0.24 ± 0.03 µmol/kg muscle·min-1; P < 0.001 and controls: -0.15 ± 0.01 vs. 0.09 ± 0.01 µmol/kg muscle·min-1; P < 0.001) but with higher net muscle phenylalanine uptake in ALC than controls (P < 0.001). Insulin concentrations were substantially higher in patients with ALC during PN. Our results suggest a higher net muscle phenylalanine uptake during a single infusion of PN in stable patients with ALC with sarcopenia compared with healthy controls.NEW & NOTEWORTHY Muscle protein turnover responses to parenteral nutritional (PN) supplementation have not previously been studied in stable alcoholic liver cirrhosis (ALC). We applied stable isotope tracers of amino acids to directly quantify net muscle protein turnover responses to PN in sarcopenic males with ALC and healthy controls. We found a higher net muscle protein gain in ALC during PN, thereby providing the physiological rationale for future clinical trials of PN as a potential countermeasure to sarcopenia.
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Affiliation(s)
- Ulrik Winning Iepsen
- The Centre for Physical Activity Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital-Hvidovre Hospital, Copenhagen, Denmark
| | - Anders Rasmussen Rinnov
- The Centre for Physical Activity Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Gregers Winding Munch
- The Centre for Physical Activity Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mette Rugbjerg
- The Centre for Physical Activity Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kamilla Munch Winding
- The Centre for Physical Activity Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Carsten Lauridsen
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Technology, Copenhagen University College, Copenhagen, Denmark
| | - Ronan M G Berg
- The Centre for Physical Activity Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, United Kingdom
| | - Bente Klarlund Pedersen
- The Centre for Physical Activity Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lise Lotte Gluud
- Gastro Unit, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Gerrit van Hall
- Clinical Metabolomics Core Facility, Clinical Biochemistry, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Biomedical Sciences, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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11
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Ravaioli F, De Maria N, Di Marco L, Pivetti A, Casciola R, Ceraso C, Frassanito G, Pambianco M, Pecchini M, Sicuro C, Leoni L, Di Sandro S, Magistri P, Menozzi R, Di Benedetto F, Colecchia A. From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients. Nutrients 2023; 15:2778. [PMID: 37375682 DOI: 10.3390/nu15122778] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/04/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Liver transplantation (LT) is a complex surgical procedure requiring thorough pre- and post-operative planning and care. The nutritional status of the patient before, during, and after LT is crucial to surgical success and long-term prognosis. This review aims to assess nutritional status assessment and management before, during, and after LT, with a focus on patients who have undergone bariatric surgery. We performed a comprehensive topic search on MEDLINE, Ovid, In-Process, Cochrane Library, EMBASE, and PubMed up to March 2023. It identifies key factors influencing the nutritional status of liver transplant patients, such as pre-existing malnutrition, the type and severity of liver disease, comorbidities, and immunosuppressive medications. The review highlights the importance of pre-operative nutritional assessment and intervention, close nutritional status monitoring, individualised nutrition care plans, and ongoing nutritional support and monitoring after LT. The review concludes by examining the effect of bariatric surgery on the nutritional status of liver transplant recipients. The review offers valuable insights into the challenges and opportunities for optimising nutritional status before, during, and after LT.
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Affiliation(s)
- Federico Ravaioli
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Nicola De Maria
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Lorenza Di Marco
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Alessandra Pivetti
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Riccardo Casciola
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Carlo Ceraso
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Gabriella Frassanito
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Martina Pambianco
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Maddalena Pecchini
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Chiara Sicuro
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Laura Leoni
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Renata Menozzi
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Antonio Colecchia
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
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12
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Wang T, Li B, Shi H, Li P, Deng Y, Wang S, Luo Q, Xv D, He J, Wang S. Short-term PET-derived kinetic estimation for the diagnosis of hepatocellular carcinoma: a combination of the maximum-slope method and dual-input three-compartment model. Insights Imaging 2023; 14:98. [PMID: 37226012 DOI: 10.1186/s13244-023-01442-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 04/24/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Kinetic estimation provides fitted parameters related to blood flow perfusion and fluorine-18-fluorodeoxyglucose (18F-FDG) transport and intracellular metabolism to characterize hepatocellular carcinoma (HCC) but usually requires 60 min or more for dynamic PET, which is time-consuming and impractical in a busy clinical setting and has poor patient tolerance. METHODS This study preliminarily evaluated the equivalence of liver kinetic estimation between short-term (5-min dynamic data supplemented with 1-min static data at 60 min postinjection) and fully 60-min dynamic protocols and whether short-term 18F-FDG PET-derived kinetic parameters using a three-compartment model can be used to discriminate HCC from the background liver tissue. Then, we proposed a combined model, a combination of the maximum-slope method and a three-compartment model, to improve kinetic estimation. RESULTS There is a strong correlation between the kinetic parameters K1 ~ k3, HPI and [Formula: see text] in the short-term and fully dynamic protocols. With the three-compartment model, HCCs were found to have higher k2, HPI and k3 values than background liver tissues, while K1, k4 and [Formula: see text] values were not significantly different between HCCs and background liver tissues. With the combined model, HCCs were found to have higher HPI, K1 and k2, k3 and [Formula: see text] values than background liver tissues; however, the k4 value was not significantly different between HCCs and the background liver tissues. CONCLUSIONS Short-term PET is closely equivalent to fully dynamic PET for liver kinetic estimation. Short-term PET-derived kinetic parameters can be used to distinguish HCC from background liver tissue, and the combined model improves the kinetic estimation. CLINICAL RELEVANCE STATEMENT Short-term PET could be used for hepatic kinetic parameter estimation. The combined model could improve the estimation of liver kinetic parameters.
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Affiliation(s)
- Tao Wang
- Yunnan Key Laboratory of Artificial Intelligence, Faculty of Information Engineering and Automation, Kunming University of Science and Technology, Kunming, 650500, Yunnan, China
| | - Boqiao Li
- Yunnan Key Laboratory of Artificial Intelligence, Faculty of Information Engineering and Automation, Kunming University of Science and Technology, Kunming, 650500, Yunnan, China
| | - Hong Shi
- Yunnan Key Laboratory of Primate Biomedical Research, Institute of Primate Translational Medicine, Kunming University of Science and Technology, Kunming, China
| | - Pengfei Li
- PET/CT Center, Affiliated Hospital of Kunming University of Science and Technology, First People's Hospital of Yunnan, Kunming, 650031, China
| | - Yinglei Deng
- PET/CT Center, Affiliated Hospital of Kunming University of Science and Technology, First People's Hospital of Yunnan, Kunming, 650031, China
| | - Siyu Wang
- PET/CT Center, Affiliated Hospital of Kunming University of Science and Technology, First People's Hospital of Yunnan, Kunming, 650031, China
| | - Qiao Luo
- PET/CT Center, Affiliated Hospital of Kunming University of Science and Technology, First People's Hospital of Yunnan, Kunming, 650031, China
| | - Dongdong Xv
- PET/CT Center, Affiliated Hospital of Kunming University of Science and Technology, First People's Hospital of Yunnan, Kunming, 650031, China
| | - Jianfeng He
- Yunnan Key Laboratory of Artificial Intelligence, Faculty of Information Engineering and Automation, Kunming University of Science and Technology, Kunming, 650500, Yunnan, China.
| | - Shaobo Wang
- PET/CT Center, Affiliated Hospital of Kunming University of Science and Technology, First People's Hospital of Yunnan, Kunming, 650031, China.
- Yunnan Key Laboratory of Primate Biomedical Research, Institute of Primate Translational Medicine, Kunming University of Science and Technology, Kunming, China.
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13
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Mpabanzi L, Wainwright J, Boonen B, van Eijk H, Dhar D, Karssemeijer E, Dejong CHC, Jalan R, Schwartz JM, Olde Damink SWM, Soons Z. Fluxomics reveals cellular and molecular basis of increased renal ammoniagenesis. NPJ Syst Biol Appl 2022; 8:49. [PMID: 36539425 PMCID: PMC9768161 DOI: 10.1038/s41540-022-00257-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 11/07/2022] [Indexed: 12/24/2022] Open
Abstract
The kidney plays a critical role in excreting ammonia during metabolic acidosis and liver failure. The mechanisms behind this process have been poorly explored. The present study combines results of in vivo experiments of increased total ammoniagenesis with systems biology modeling, in which eight rats were fed an amino acid-rich diet (HD group) and eight a normal chow diet (AL group). We developed a method based on elementary mode analysis to study changes in amino acid flux occurring across the kidney in increased ammoniagenesis. Elementary modes represent minimal feasible metabolic paths in steady state. The model was used to predict amino acid fluxes in healthy and pre-hyperammonemic conditions, which were compared to experimental fluxes in rats. First, we found that total renal ammoniagenesis increased from 264 ± 68 to 612 ± 87 nmol (100 g body weight)-1 min-1 in the HD group (P = 0.021) and a concomitated upregulation of NKCC2 ammonia and other transporters in the kidney. In the kidney metabolic model, the best predictions were obtained with ammonia transport as an objective. Other objectives resulting in a fair correlation with the measured fluxes (correlation coefficient >0.5) were growth, protein uptake, urea excretion, and lysine and phenylalanine transport. These predictions were improved when specific gene expression data were considered in HD conditions, suggesting a role for the mitochondrial glycine pathway. Further studies are needed to determine if regulation through the mitochondrial glycine pathway and ammonia transporters can be modulated and how to use the kidney as a therapeutic target in hyperammonemia.
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Affiliation(s)
- Liliane Mpabanzi
- grid.5012.60000 0001 0481 6099Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands ,grid.83440.3b0000000121901201Hepato-Pancreato-Biliary and Liver Transplant Surgery, Royal Free Hospital, University College London, Pond Street, London, NW3 2QG UK ,grid.83440.3b0000000121901201Liver Failure Group, UCL Hepatology, Royal Free Hospital, University College London, Pond Street, London, NW3 2QG UK
| | - Jessica Wainwright
- grid.5379.80000000121662407School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PT UK
| | - Bas Boonen
- grid.5012.60000 0001 0481 6099Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands
| | - Hans van Eijk
- grid.5012.60000 0001 0481 6099Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands
| | - Dipok Dhar
- grid.83440.3b0000000121901201Hepato-Pancreato-Biliary and Liver Transplant Surgery, Royal Free Hospital, University College London, Pond Street, London, NW3 2QG UK
| | - Esther Karssemeijer
- grid.5012.60000 0001 0481 6099Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands
| | - Cees H. C. Dejong
- grid.5012.60000 0001 0481 6099Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands ,grid.412301.50000 0000 8653 1507Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Rajiv Jalan
- grid.83440.3b0000000121901201Liver Failure Group, UCL Hepatology, Royal Free Hospital, University College London, Pond Street, London, NW3 2QG UK
| | - Jean-Marc Schwartz
- grid.5379.80000000121662407School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PT UK
| | - Steven W. M. Olde Damink
- grid.5012.60000 0001 0481 6099Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands ,grid.83440.3b0000000121901201Hepato-Pancreato-Biliary and Liver Transplant Surgery, Royal Free Hospital, University College London, Pond Street, London, NW3 2QG UK ,grid.412301.50000 0000 8653 1507Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Zita Soons
- grid.5012.60000 0001 0481 6099Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands ,grid.412301.50000 0000 8653 1507Research Center for Computational Biomedicine, University Hospital RWTH Aachen, Aachen, Germany
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14
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Haj Ali S, Abu Sneineh A, Hasweh R. Nutritional assessment in patients with liver cirrhosis. World J Hepatol 2022; 14:1694-1703. [PMID: 36185724 PMCID: PMC9521456 DOI: 10.4254/wjh.v14.i9.1694] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/09/2022] [Accepted: 09/09/2022] [Indexed: 02/06/2023] Open
Abstract
Malnutrition is a liver cirrhosis complication affecting more than 20%-50% of patients. Although the term can refer to either nutrient deficiency or excess, it usually relates to undernutrition in cirrhosis settings. Frailty is defined as limited physical function due to muscle weakness, whereas sarcopenia is defined as muscle mass loss and an advanced malnutrition stage. The pathogenesis of malnutrition in liver cirrhosis is multifactorial, including decreased oral intake, maldigestion/malabsorption, physical inactivity, hyperammonemia, hypermetabolism, altered macronutrient metabolism and gut microbiome dysbiosis. Patients with chronic liver disease with a Body Mass Index of < 18.5 kg/m2 and/or decompensated cirrhosis or Child-Pugh class C are at the highest risk of malnutrition. For patients at risk of malnutrition, a detailed nutritional assessment is required, typically including a history and physical examination, laboratory testing, global assessment tools and body composition testing. The latter can be done using anthropometry, cross-sectional imaging including computed tomography or magnetic resonance, bioelectrical impedance analysis and dual-energy X-ray absorptiometry. A multidisciplinary team should screen for and treat malnutrition in patients with cirrhosis. Malnutrition and sarcopenia are associated with an increased risk of complications and a poor prognosis in patients with liver cirrhosis; thus, it is critical to diagnose these conditions early and initiate the appropriate nutritional therapy. In this review, we describe the prevalence and pathogenesis of malnutrition in liver cirrhosis patients and discuss the best diagnostic approach to nutritional assessment for them.
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Affiliation(s)
- Sara Haj Ali
- Department of Internal Medicine, Faculty of Medicine, Al-Balqa Applied University, Salt 19117, Jordan
| | - Awni Abu Sneineh
- Department of Gastroenterology and Hepatology, University of Jordan, Faculty of Medicine, Amman 11942, Jordan
| | - Reem Hasweh
- Department of Internal Medicine, Faculty of Medicine, Al-Balqa Applied University, Salt 19117, Jordan
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15
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Malnutrition as a risk factor of adverse postoperative outcomes in patients undergoing hepatic resection: analysis of US hospitals. Br J Nutr 2022; 128:675-683. [PMID: 34551838 DOI: 10.1017/s0007114521003809] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Patients with liver cancer or space-occupying cysts suffer from malnutrition due to compression of gastric and digestive structures, liver and cancer-mediated dysmetabolism, and impaired nutrient absorption. As proportion of these patients requires removal of lesions through hepatic resection, it is important to evaluate the effects of malnutrition on post-hepatectomy outcomes. In our study approach, 2011-2017 National Inpatient Sample was used to isolate in-hospital hepatectomy cases, which were stratified using malnutrition (composite of malnutrition, sarcopenia and weight loss/cachexia). The malnutrition-absent controls were matched to cases using nearest neighbour propensity score matching method and compared with the following endpoints: mortality, length of stay, hospitalisation costs and postoperative complications. There were 2531 patients in total who underwent hepatectomy with matched number of controls from the database; following the match, malnutrition cohort (compared with controls) was more likely to experience in-hospital death (6·60 % v. 5·25 % P < 0·049, OR 1·27, 95 % CI 1·01, 1·61) and was more likely to have higher length of stay (18·10 d v. 9·32 d, P < 0·001) and hospitalisation costs ($278 780 v. $150 812, P < 0·001). In terms of postoperative complications, malnutrition cohort was more likely to experience bleeding (6·52 % v. 3·87 %, P < 0·001, OR 1·73, 95 % CI 1·34, 2·24), infection (6·64 % v. 2·49 %, P < 0·001, OR 2·79, 95 % CI 2·07, 3·74), wound complications (4·5 % v. 1·38 %, P < 0·001, OR 3·36, 95 % CI 2·29, 4·93) and respiratory failure (9·40 % v. 4·11 %, P < 0·001, OR 2·42, 95 % CI 1·91, 3·07). In multivariate analysis, malnutrition was associated with higher mortality (P < 0·028, adjusted OR 1·3, 95 % CI 1·03, 1·65). Thus, we conclude that malnutrition is a risk factor of postoperative mortality in patients undergoing hepatectomy.
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16
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Protein Catabolism and the Dysregulation of Energy Intake-Related Hormones May Play a Major Role in the Worsening of Malnutrition in Hospitalized Cirrhotic Patients. LIVERS 2022. [DOI: 10.3390/livers2030014] [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] [Indexed: 11/16/2022] Open
Abstract
Malnutrition in cirrhotic patients is extremely common and has a multifactorial aetiology, whose constitutive elements have not been completely elucidated yet. Protein depletion is particularly important and an imbalance of hormones regulating hunger and satiety may be an important additive factor. The diagnosis and treatment of malnutrition are extremely important since malnutrition is associated with higher complication rates and mortality. Our observational study aimed to study protein status and energy intake-related hormone levels in a cohort of hospitalized cirrhotic patients. We enrolled 50 hospitalized and clinically stable cirrhotic patients and assessed their nutritional status with anthropometric measurements and nitrogen balance. In a subgroup of 16 patients and 10 healthy controls, circulating ghrelin and leptin levels were studied. We observed that 60% of our patients were malnourished on the basis of the mid-arm muscle circumference values; the recorded daily protein intake was tendentially insufficient (mean protein intake of 0.7 ± 0.5 g protein/kg vs. recommended intake of 1.2–1.5 g of protein/kg/die). Cirrhotic patients had lower circulating levels of both ghrelin and leptin compared to healthy controls. In conclusion, hospitalized cirrhotic patients face a catabolic state and an imbalance in hormones regulating food intake and satiety, and these elements may play a major role in the genesis and/or the worsening of malnutrition.
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17
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Paulusma CC, Lamers W, Broer S, van de Graaf SFJ. Amino acid metabolism, transport and signalling in the liver revisited. Biochem Pharmacol 2022; 201:115074. [PMID: 35568239 DOI: 10.1016/j.bcp.2022.115074] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 11/02/2022]
Abstract
The liver controls the systemic exposure of amino acids entering via the gastro-intestinal tract. For most amino acids except branched chain amino acids, hepatic uptake is very efficient. This implies that the liver orchestrates amino acid metabolism and also controls systemic amino acid exposure. Although many amino acid transporters have been identified, cloned and investigated with respect to substrate specificity, transport mechanism, and zonal distribution, which of these players are involved in hepatocellular amino acid transport remains unclear. Here, we aim to provide a review of current insight into the molecular machinery of hepatic amino acid transport. Furthermore, we place this information in a comprehensive overview of amino acid transport, signalling and metabolism.
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Affiliation(s)
- Coen C Paulusma
- Tytgat Institute for Liver and Intestinal Research, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands; Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Wouter Lamers
- Tytgat Institute for Liver and Intestinal Research, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands; Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, Netherlands; Department of Anatomy & Embryology, Maastricht University, Maastricht, The Netherlands
| | - Stefan Broer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, Netherlands; Research School of Biology, Australian National University, Canberra, Australia
| | - Stan F J van de Graaf
- Tytgat Institute for Liver and Intestinal Research, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands; Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Department of Anatomy & Embryology, Maastricht University, Maastricht, The Netherlands.
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18
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Lai JC, Tandon P, Bernal W, Tapper EB, Ekong U, Dasarathy S, Carey EJ. Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 74:1611-1644. [PMID: 34233031 PMCID: PMC9134787 DOI: 10.1002/hep.32049] [Citation(s) in RCA: 268] [Impact Index Per Article: 89.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 06/23/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Jennifer C Lai
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Puneeta Tandon
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Albert, Canada
| | - William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Elliot B Tapper
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI
| | - Udeme Ekong
- Georgetown University School of Medicine, Medstar Georgetown Transplant Institute, Washington, DC
| | - Srinivasan Dasarathy
- Department of Gastroenterology and Hepatology, Inflammation and Immunity, Lerner Research Institute, Cleveland Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic in Arizona, Phoenix, AZ
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19
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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: 7] [Impact Index Per Article: 2.3] [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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20
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Bezborodkina NN, Okovityi SV, Kudryavtsev BN. Postprandial Glycogen Content Is Increased in the Hepatocytes of Human and Rat Cirrhotic Liver. Cells 2021; 10:cells10050976. [PMID: 33919385 PMCID: PMC8143336 DOI: 10.3390/cells10050976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/09/2021] [Accepted: 04/20/2021] [Indexed: 12/25/2022] Open
Abstract
Chronic hepatitises of various etiologies are widespread liver diseases in humans. Their final stage, liver cirrhosis (LC), is considered to be one of the main causes of hepatocellular carcinoma (HCC). About 80-90% of all HCC cases develop in LC patients, which suggests that cirrhotic conditions play a crucial role in the process of hepatocarcinogenesis. Carbohydrate metabolism in LC undergoes profound disturbances characterized by altered glycogen metabolism. Unfortunately, data on the glycogen content in LC are few and contradictory. In this study, the material was obtained from liver biopsies of patients with LC of viral and alcohol etiology and from the liver tissue of rats with CCl4-induced LC. The activity of glycogen phosphorylase (GP), glycogen synthase (GS), and glucose-6-phosphatase (G6Pase) was investigated in human and rat liver tissue by biochemical methods. Total glycogen and its labile and stable fractions were measured in isolated individual hepatocytes, using the cytofluorometry technique of PAS reaction in situ. The development of LC in human and rat liver was accompanied by an increase in fibrous tissue (20- and 8.8-fold), an increase in the dry mass of hepatocytes (by 25.6% and 23.7%), and a decrease in the number of hepatocytes (by 50% and 28%), respectively. The rearrangement of the liver parenchyma was combined with changes in glycogen metabolism. The present study showed a significant increase in the glycogen content in the hepatocytes of the human and the rat cirrhotic liver, by 255% and 210%, respectively. An increased glycogen content in cells of the cirrhotic liver can be explained by a decrease in glycogenolysis due to a decreased activity of G6Pase and GP.
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Affiliation(s)
- Natalia N. Bezborodkina
- Zoological Institute, Russian Academy of Sciences, Universitetskaya nab. 1, 199034 St. Petersburg, Russia
- Correspondence: or
| | - Sergey V. Okovityi
- Department of Pharmacology and Clinical Pharmacology, Saint Petersburg State Chemical Pharmaceutical University, 197022 St. Petersburg, Russia;
| | - Boris N. Kudryavtsev
- Scientific-Clinical Centre, Pavlov First Saint Petersburg State Medical University, L’va Tolstogo str. 6-8, 197022 St. Petersburg, Russia;
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21
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Becker D, Eshmuminov D, Keller R, Mueller M, Bautista Borrego L, Hagedorn C, Duskabilova M, Tibbitt MW, Onder C, Clavien PA, Rudolf von Rohr P, Schuler MJ, Hefti M. Automated Insulin Delivery - Continuous Blood Glucose Control During Ex Situ Liver Perfusion. IEEE Trans Biomed Eng 2021; 68:1399-1408. [DOI: 10.1109/tbme.2020.3033663] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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22
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Kim Y. Emerging Treatment Options for Sarcopenia in Chronic Liver Disease. Life (Basel) 2021; 11:life11030250. [PMID: 33803020 PMCID: PMC8002763 DOI: 10.3390/life11030250] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/13/2021] [Accepted: 03/15/2021] [Indexed: 12/17/2022] Open
Abstract
Sarcopenia is characterized by a skeletal muscle disorder with progressive and generalized loss of muscle mass and function, and it increases the risk of adverse outcomes with considerable prevalence in patients with chronic liver disease. Sarcopenia in chronic liver disease underlies complicated and multifactorial mechanisms for pathogenesis, including alterations in protein turnover, hyperammonemia, energy disposal, hormonal changes, and chronic inflammation. The key contribution to sarcopenia in patients with chronic liver diseases can be the hyperammonemia-induced upregulation of myostatin, which causes muscle atrophy via the expression of atrophy-related genes. Several clinical studies on emerging treatment options for sarcopenia have been reported, but only a few have focused on patients with chronic liver diseases, with mostly nutritional and behavioral interventions being carried out. The inhibition of the myostatin-activin receptor signaling pathway and hormonal therapy might be the most promising therapeutic options in combination with an ammonia-lowering approach in sarcopenic patients with chronic liver diseases. This review focuses on current and emerging treatment options for sarcopenia in chronic liver diseases with underlying mechanisms to counteract this condition.
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Affiliation(s)
- Yun Kim
- Hanyang Medicine-Engineering-Bio Collaborative & Comprehensive Center for Drug Development, Hanyang University, Seoul 04763, Korea
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23
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Traub J, Reiss L, Aliwa B, Stadlbauer V. Malnutrition in Patients with Liver Cirrhosis. Nutrients 2021; 13:540. [PMID: 33562292 PMCID: PMC7915767 DOI: 10.3390/nu13020540] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/04/2021] [Accepted: 02/04/2021] [Indexed: 12/13/2022] Open
Abstract
Liver cirrhosis is an increasing public health threat worldwide. Malnutrition is a serious complication of cirrhosis and is associated with worse outcomes. With this review, we aim to describe the prevalence of malnutrition, pathophysiological mechanisms, diagnostic tools and therapeutic targets to treat malnutrition. Malnutrition is frequently underdiagnosed and occurs-depending on the screening methods used and patient populations studied-in 5-92% of patients. Decreased energy and protein intake, inflammation, malabsorption, altered nutrient metabolism, hypermetabolism, hormonal disturbances and gut microbiome dysbiosis can contribute to malnutrition. The stepwise diagnostic approach includes a rapid prescreen, the use of a specific screening tool, such as the Royal Free Hospital Nutritional Prioritizing Tool and a nutritional assessment by dieticians. General dietary measures-especially the timing of meals-oral nutritional supplements, micronutrient supplementation and the role of amino acids are discussed. In summary malnutrition in cirrhosis is common and needs more attention by health care professionals involved in the care of patients with cirrhosis. Screening and assessment for malnutrition should be carried out regularly in cirrhotic patients, ideally by a multidisciplinary team. Further research is needed to better clarify pathogenic mechanisms such as the role of the gut-liver-axis and to develop targeted therapeutic strategies.
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Affiliation(s)
- Julia Traub
- Department of Clinical Medical Nutrition, University Hospital Graz, 8036 Graz, Austria; (J.T.); (L.R.)
| | - Lisa Reiss
- Department of Clinical Medical Nutrition, University Hospital Graz, 8036 Graz, Austria; (J.T.); (L.R.)
| | - Benard Aliwa
- Department of Gastroenterology and Hepatology, Medical University of Graz, 8036 Graz, Austria;
| | - Vanessa Stadlbauer
- Department of Gastroenterology and Hepatology, Medical University of Graz, 8036 Graz, Austria;
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24
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Chapman B, Sinclair M, Gow PJ, Testro AG. Malnutrition in cirrhosis: More food for thought. World J Hepatol 2020; 12:883-896. [PMID: 33312416 PMCID: PMC7701970 DOI: 10.4254/wjh.v12.i11.883] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/08/2020] [Accepted: 10/20/2020] [Indexed: 02/06/2023] Open
Abstract
Malnutrition is highly prevalent in liver cirrhosis and its presence carries important prognostic implications. The clinical conditions and pathophysiological mechanisms that cause malnutrition in cirrhosis are multiple and interrelated. Anorexia and liver decompensation symptoms lead to poor dietary intake; metabolic changes characterised by elevated energy expenditure, reduced glycogen storage, an accelerated starvation response and protein catabolism result in muscle and fat wasting; and, malabsorption renders the cirrhotic patient unable to fully absorb or utilise food that has been consumed. Malnutrition is therefore a considerable challenge to manage effectively, particularly as liver disease progresses. A high energy, high protein diet is recognised as standard of care, yet patients struggle to follow this recommendation and there is limited evidence to guide malnutrition interventions in cirrhosis and liver transplantation. In this review, we seek to detail the factors which contribute to poor nutritional status in liver disease, and highlight complexities far greater than "poor appetite" or "reduced oral intake" leading to malnutrition. We also discuss management strategies to optimise nutritional status in this patient group, which target the inter-related mechanisms unique to advanced liver disease. Finally, future research requirements are suggested, to develop effective treatments for one of the most common and debilitating complications afflicting cirrhotic patients.
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Affiliation(s)
- Brooke Chapman
- Nutrition and Dietetics Department, Austin Health, Heidelberg 3084, Australia.
| | - Marie Sinclair
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
| | - Paul J Gow
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
| | - Adam G Testro
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
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25
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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: 141] [Impact Index Per Article: 35.3] [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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Philips CA, Ahamed R, Rajesh S, George T, Mohanan M, Augustine P. Update on diagnosis and management of sepsis in cirrhosis: Current advances. World J Hepatol 2020; 12:451-474. [PMID: 32952873 PMCID: PMC7475781 DOI: 10.4254/wjh.v12.i8.451] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/28/2020] [Accepted: 06/27/2020] [Indexed: 02/06/2023] Open
Abstract
Sepsis and septic shock are catastrophic disease entities that portend high mortality in patients with cirrhosis. In cirrhosis, hemodynamic perturbations, immune dysregulation, and persistent systemic inflammation with altered gut microbiota in the background of portal hypertension enhance the risk of infections and resistance to antimicrobials. Patients with cirrhosis develop recurrent life-threatening infections that progress to multiple organ failure. The definition, pathophysiology, and treatment options for sepsis have been ever evolving. In this exhaustive review, we discuss novel advances in the understanding of sepsis, describe current and future biomarkers and scoring systems for sepsis, and delineate newer modalities and adjuvant therapies for the treatment of sepsis from existing literature to extrapolate the same concerning the management of sepsis in cirrhosis. We also provide insights into the role of gut microbiota in initiation and progression of sepsis and finally, propose a treatment algorithm for management of sepsis in patients with cirrhosis.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anaesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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27
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Santos BC, Correia MITD, Anastácio LR. Energy Expenditure and Liver Transplantation: What We Know and Where We Are. JPEN J Parenter Enteral Nutr 2020; 45:456-464. [DOI: 10.1002/jpen.1985] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Bárbara Chaves Santos
- Food Science Post Graduation Program Universidade Federal de Minas Gerais Belo Horizonte Brazil
| | - Maria Isabel Toulson Davisson Correia
- Food Science Post Graduation Program Universidade Federal de Minas Gerais Belo Horizonte Brazil
- Surgery Department Universidade Federal de Minas Gerais Belo Horizonte Brazil
| | - Lucilene Rezende Anastácio
- Food Science Post Graduation Program Universidade Federal de Minas Gerais Belo Horizonte Brazil
- Food Science Department Universidade Federal de Minas Gerais Belo Horizonte Brazil
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28
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Kosenko E, Tikhonova L, Alilova G, Montoliu C. A Look into Liver Mitochondrial Dysfunction as a Hallmark in Progression of Brain Energy Crisis and Development of Neurologic Symptoms in Hepatic Encephalopathy. J Clin Med 2020; 9:E2259. [PMID: 32708652 PMCID: PMC7408643 DOI: 10.3390/jcm9072259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/18/2020] [Accepted: 07/13/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The relationship between liver disease and neuropathology in hepatic encephalopathy is well known, but the genesis of encephalopathy in liver failure is yet to be elucidated. Conceptually, the main cause of hepatic encephalopathy is the accumulation of brain ammonia due to impaired liver detoxification function or occurrence of portosystemic shunt. Yet, as well as taking up toxic ammonia, the liver also produces vital metabolites that ensure normal cerebral function. Given this, for insight into how perturbations in the metabolic capacity of the liver may be related to brain pathology, it is crucial to understand the extent of ammonia-related changes in the hepatic metabolism that provides respiratory fuel for the brain, a deficiency of which can give rise to encephalopathy. METHODS Hepatic encephalopathy was induced in starved rats by injection of ammonium acetate. Ammonia-induced toxicity was evaluated by plasma and freeze-clamped liver and brain energy metabolites, and mitochondrial, cytoplasmic, and microsomal gluconeogenic enzymes, including mitochondrial ketogenic enzymes. Parameters of oxidative phosphorylation were recorded polarographically with a Clark-type electrode, while other measures were determined with standard fluorometric enzymatic methods. RESULTS Progressive impairment of liver mitochondrial respiration in the initial stage of ammonia-induced hepatotoxicity and the subsequent energy crisis due to decreased ATP synthesis lead to cessation of gluconeogenesis and ketogenesis. Reduction in glucose and ketone body supply to the brain is a terminal event in liver toxicity, preceding the development of coma. CONCLUSIONS Our study provides a framework to further explore the relationship between hepatic dysfunction and progression of brain energy crisis in hepatic encephalopathy.
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Affiliation(s)
- Elena Kosenko
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 142290 Pushchino, Russia; (L.T.); (G.A.)
| | - Lyudmila Tikhonova
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 142290 Pushchino, Russia; (L.T.); (G.A.)
| | - Gubidat Alilova
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 142290 Pushchino, Russia; (L.T.); (G.A.)
| | - Carmina Montoliu
- Hospital Clinico Research Foundation, INCLIVA Health Research Institute, 46010 Valencia, Spain;
- Pathology Department, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain
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Miyaaki H, Kobayashi H, Miuma S, Fukusima M, Sasaki R, Haraguchi M, Nakao K. Blood carnitine profiling on tandem mass spectrometry in liver cirrhotic patients. BMC Gastroenterol 2020; 20:41. [PMID: 32075591 PMCID: PMC7029602 DOI: 10.1186/s12876-020-01190-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 02/11/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The level and profiles of blood free carnitine and acylcarnitines, obtained by acylcarnitine analysis using tandem mass spectrometry, reflect various metabolic conditions. We aimed to examine the level of free carnitine and acylcarnitines in liver cirrhosis patients by acylcarnitine analysis and determine the clinical and subjective factors associated with blood carnitine fraction levels in liver cirrhosis. METHODS We compared blood carnitine fractions in 54 liver cirrhotic patients to other laboratory test results and questionnaire answers. RESULTS In almost all patients, the blood levels of free carnitine (C0) and acetylcarnitine (C2) were within the normal reference range. However, in some patients, the levels of long-chain acylcarnitines, such as C16 and C18:1-acylcarnitine, were higher than the normal reference range. Liver function, assessed by Child-Pugh score, was significantly correlated with the blood level of each carnitine fraction measured (C0, C2, C3, C4, C6, C10, C12, C12:1, C14:1, C16, C18:1, and C18:2-acylcarnitine). Cirrhotic symptom score was significantly correlated with C0, C2, C3, C16, and C18-1-acylcarnitine blood levels. Among the 36-item short-form health survey (SF-36) items, the physical component summary was significantly associated with C0, C2, and C18-1-acylcarnitine blood levels. CONCLUSIONS Carnitine fraction levels were positively correlated with liver cirrhosis stage, particularly, long-chain acylcarnitines. Moreover, carnitine fraction levels were associated with various subjective physical symptoms in liver cirrhosis patients.
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Affiliation(s)
- Hisamitsu Miyaaki
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Hironori Kobayashi
- Department of Pediatrics, Shimane University Faculty of Medicine, 89-1 Enya, Izumo, Shimane, 693-8501, Japan
| | - Satoshi Miuma
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Masanori Fukusima
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Ryu Sasaki
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Masafumi Haraguchi
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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30
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Bunchorntavakul C, Reddy KR. Review article: malnutrition/sarcopenia and frailty in patients with cirrhosis. Aliment Pharmacol Ther 2020; 51:64-77. [PMID: 31701570 DOI: 10.1111/apt.15571] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/20/2019] [Accepted: 10/13/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Malnutrition/sarcopenia and frailty are common in patients with cirrhosis and are associated with poor outcomes. AIM To provide an overview of data on the importance, assessment and management of malnutrition/sarcopenia and frailty in cirrhosis. METHODS A literature search was conducted in PubMed and other sources, using the search terms "sarcopenia," "muscle," "malnutrition," "cirrhosis," "liver" and "frailty" from inception to April 2019, to identify the relevant studies and international guidelines. RESULTS The prevalence of malnutrition/sarcopenia in cirrhosis is 23%-60%. Frailty generally overlaps with malnutrition/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/sarcopenia in cirrhosis is complex/multifactorial and not just reduction in protein/calorie intake. Hyperammonemia appears to be the main driver of sarcopenia in cirrhosis through several molecular signalling pathways. 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, they, 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. CONCLUSIONS Malnutrition/sarcopenia and frailty are unique, inter-related and multi-dimensional 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)
- Chalermrat Bunchorntavakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Fallahzadeh MA, Rahimi RS. Hepatic Encephalopathy and Nutrition Influences: A Narrative Review. Nutr Clin Pract 2019; 35:36-48. [PMID: 31872484 DOI: 10.1002/ncp.10458] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Hepatic encephalopathy (HE) is a potentially reversible neurocognitive condition seen in patients with advanced liver disease. The overt form of HE has been reported in up to 45% of patients with cirrhosis. This debilitating condition is associated with increased morbidity and mortality and imposes a significant burden on the caregivers and healthcare system. After providing an overview of HE epidemiology and pathophysiology, this review focuses on the interaction of HE and frailty, nutrition requirements and recommendations in cirrhotic patients with HE, and current dietary and pharmacologic options for HE treatment.
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Affiliation(s)
- Mohammad Amin Fallahzadeh
- Division of Hepatology, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Robert S Rahimi
- Division of Hepatology, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
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Jeong HM, Kim DJ. Bone Diseases in Patients with Chronic Liver Disease. Int J Mol Sci 2019; 20:E4270. [PMID: 31480433 PMCID: PMC6747370 DOI: 10.3390/ijms20174270] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 08/25/2019] [Accepted: 08/28/2019] [Indexed: 02/07/2023] Open
Abstract
Osteoporosis is a frequently observed complication in patients with chronic liver disease, particularly liver cirrhosis and cholestatic liver diseases. In addition, osteoporosis is critical in patients receiving a liver transplant. Nevertheless, few studies have evaluated bone diseases in patients with more frequently observed chronic liver disease, such as chronic viral hepatitis, nonalcoholic fatty liver disease and alcoholic liver disease. Osteoporosis is a disease caused by an imbalance in the activities of osteoblasts and osteoclasts. Over the last few decades, many advances have improved our knowledge of the pathogenesis of osteoporosis. Importantly, activated immune cells affect the progression of osteoporosis, and chronic inflammation may exert an additional effect on the existing pathophysiology of osteoporosis. The microbiota of the intestinal tract may also affect the progression of bone loss in patients with chronic liver disease. Recently, studies regarding the effects of chronic inflammation on dysbiosis in bone diseases have been conducted. However, mechanisms underlying osteoporosis in patients with chronic liver disease are complex and precise mechanisms remain unknown. The following special considerations in patients with chronic liver disease are reviewed: bone diseases in patients who underwent a liver transplant, the association between chronic hepatitis B virus infection treatment and bone diseases, the association between sarcopenia and bone diseases in patients with chronic liver disease, and the association between chronic liver disease and avascular necrosis of the hip. Few guidelines are currently available for the management of low bone mineral density or bone diseases in patients with chronic liver disease. Due to increased life expectancy and therapeutic advances in chronic liver disease, the importance of managing osteoporosis and other bone diseases in patients with chronic liver disease is expected to increase. Consequently, specific guidelines need to be established in the near future.
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Affiliation(s)
- Hae Min Jeong
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Gangwon-do 24253, Korea
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, Gangwon-do 24253, Korea
| | - Dong Joon Kim
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon, Gangwon-do 24253, Korea.
- Department of Internal Medicine, Hallym University College of Medicine, Seoul 05355, Korea.
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Indirect Calorimetry Performance Using a Handheld Device Compared to the Metabolic Cart in Outpatients with Cirrhosis. Nutrients 2019; 11:nu11051030. [PMID: 31071956 PMCID: PMC6566822 DOI: 10.3390/nu11051030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 04/29/2019] [Accepted: 05/06/2019] [Indexed: 12/23/2022] Open
Abstract
Addressing malnutrition is important to improve health outcomes in outpatients with cirrhosis, yet assessing energy requirements in this population is challenging. Predictive equations of resting energy expenditure (REE) are thought to be unreliable, and traditional indirect calorimetry is expensive and infrequently available for clinical use. The accuracy of REE predictions using a MedGem® handheld indirect calorimeter, the Harris Benedict Equation (HBE), the Mifflin St. Jeor equation (MSJ), and the gold standard Vmax Encore® (Vmax) metabolic cart was compared. The REE of cirrhotic pre-liver transplant outpatients was analyzed using each of the four methods. Agreement between methods was calculated using Bland-Altman analysis. Fourteen patients with cirrhosis participated, and were primarily male (71%) and malnourished (subjective global assessment (SGA) B or C 64%). Lin's concordance coefficient (ρC) for MedGem® vs. Vmax demonstrated poor levels of precision and accuracy (ρC = 0.80, 95% confidence interval 0.55-0.92) between measures, as did the HBE compared to Vmax (ρC = 0.56, 95% confidence interval 0.19-0.79). Mean REE by MedGem® was similar to that measured by Vmax (-1.5%); however, only 21% of REE measures by MedGem® were within ±5% of Vmax measures. Wide variability limits the use of MedGem® at an individual level; a more accurate and feasible method for determination of REE in patients with cirrhosis and malnutrition is needed.
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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: 332] [Impact Index Per Article: 66.4] [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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35
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Abstract
Food plays an essential role in normal cellular processes; however, certain foods may also trigger or worsen certain disease states. This article focuses particularly on the role of food in common gastrointestinal and liver diseases, and discusses the current evidence that either supports or debunks common dietary recommendations. Nutrition topics discussed include the use of artificial sweetener for weight loss, avoidance of all dairy products in the setting of lactose intolerance, dietary recommendations for diverticular disease, and dietary management in cirrhotic patients with hepatic encephalopathy.
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Affiliation(s)
- Michelle Pearlman
- Gastroenterology and Hepatology Fellow, Department of Internal Medicine, Division of Digestive and Liver Diseases, University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390-9151, USA.
| | - Oviea Akpotaire
- Department of Internal Medicine, University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390-9151, USA
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Exercise in cirrhosis: Translating evidence and experience to practice. J Hepatol 2018; 69:1164-1177. [PMID: 29964066 DOI: 10.1016/j.jhep.2018.06.017] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/21/2018] [Accepted: 06/22/2018] [Indexed: 02/06/2023]
Abstract
Physical inactivity, sarcopenia, and frailty are highly prevalent, independent predictors of morbidity and mortality in patients with cirrhosis. Across a range of chronic diseases, exercise training is a key recommendation supported by guidelines and, for some conditions, even by governmental funding of exercise programmes. Consistent with the broader chronic disease literature, the evidence for a benefit of exercise in cirrhosis is promising. Several small trials have reported significant improvements in muscle health (mass, strength, functional capacity), quality of life, fatigue, and reductions in the hepatic venous pressure gradient, without adverse events. With strong emerging evidence surrounding the substantial risks of sarcopenia/frailty and our first-hand experiences with liver pre-transplant exercise programmes, we contend that routine patient care in cirrhosis should include an exercise prescription. Some clinicians may lack the resources and necessary background to translate the existing evidence into a practicable intervention. Our team, comprised of physiotherapists, exercise physiologists, hepatologists, transplant specialists, and knowledge translation experts from six North American centres, has distilled the essential background information, tools, and practices into a set of information ready for immediate implementation into clinics ranging from a family practice setting to specialty cirrhosis clinics. Augmenting the rationale and evidence are supplementary materials including video and downloadable materials for both patients and the physician. Supporting the exercising patient is a section regarding information about nutrition, providing practical tips suitable for all patients with cirrhosis.
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Affiliation(s)
- Jennifer C Lai
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California, San Francisco, CA, USA. Cirrhosis Care Clinic, Division of Gastroenterology & Hepatology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Puneeta Tandon
- Division of Gastroenterology & Hepatology, Department of Medicine, University of California, San Francisco, CA, USA. Cirrhosis Care Clinic, Division of Gastroenterology & Hepatology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Shuja A, Malespin M, Scolapio J. Nutritional Considerations in Liver Disease. Gastroenterol Clin North Am 2018; 47:243-252. [PMID: 29413017 DOI: 10.1016/j.gtc.2017.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Malnutrition occurs in most patients with advanced liver diseases and is associated with higher rates of morbidity and mortality. In this article, the authors discuss the pathophysiology of malnutrition and methods to optimize nutrition status in liver disease and include a brief section on perioperative and postoperative nutrition.
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Affiliation(s)
- Asim Shuja
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, 4555 Emerson Street, Suite 300, Jacksonville, FL 32207, USA.
| | - Miguel Malespin
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, 4555 Emerson Street, Suite 300, Jacksonville, FL 32207, USA
| | - James Scolapio
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, 4555 Emerson Street, Suite 300, Jacksonville, FL 32207, USA
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Mitochondrial Mutations in Cholestatic Liver Disease with Biliary Atresia. Sci Rep 2018; 8:905. [PMID: 29343773 PMCID: PMC5772057 DOI: 10.1038/s41598-017-18958-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 12/19/2017] [Indexed: 12/25/2022] Open
Abstract
Biliary atresia (BA) results in severe bile blockage and is caused by the absence of extrahepatic ducts. Even after successful hepatic portoenterostomy, a considerable number of patients are likely to show progressive deterioration in liver function. Recent studies show that mutations in protein-coding mitochondrial DNA (mtDNA) genes and/or mitochondrial genes in nuclear DNA (nDNA) are associated with hepatocellular dysfunction. This observation led us to investigate whether hepatic dysfunctions in BA is genetically associated with mtDNA mutations. We sequenced the mtDNA protein-coding genes in 14 liver specimens from 14 patients with BA and 5 liver specimens from 5 patients with choledochal cyst using next-generation sequencing. We found 34 common non-synonymous variations in mtDNA protein-coding genes in all patients examined. A systematic 3D structural analysis revealed the presence of several single nucleotide polymorphism-like mutations in critical regions of complexes I to V, that are involved in subunit assembly, proton-pumping activity, and/or supercomplex formation. The parameters of chronic hepatic injury and liver dysfunction in BA patients were also significantly correlated with the extent of hepatic failure, suggesting that the mtDNA mutations may aggravate hepatopathy. Therefore, mitochondrial mutations may underlie the pathological mechanisms associated with BA.
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Abstract
As the cirrhosis progresses, development of complication like ascites, hepatic encephalopathy, variceal bleeding, kidney dysfunction, and hepatocellular carcinoma signify increasing risk of short term mortality. Malnutrition and muscle wasting (sarcopenia) is yet other complications that negatively impact survival, quality of life, and response to stressors, such as infection and surgery in patients with cirrhosis. Conventionally, these are not routinely looked for, because nutritional assessment can be a difficult especially if there is associated fluid retention and/or obesity. Patients with cirrhosis may have a combination of loss of skeletal muscle and gain of adipose tissue, culminating in the condition of "sarcopenic obesity." Sarcopenia in cirrhotic patients has been associated with increased mortality, sepsis complications, hyperammonemia, overt hepatic encephalopathy, and increased length of stay after liver transplantation. Assessment of muscles with cross-sectional imaging studies has become an attractive index of nutritional status evaluation in cirrhosis, as sarcopenia, the major component of malnutrition, is primarily responsible for the adverse clinical consequences seen in patients with liver disease. Cirrhosis is a state of accelerated starvation, with increased gluconeogenesis that requires amino acid diversion from other metabolic functions. Protein homeostasis is disturbed in cirrhosis due to several factors such as hyperammonemia, hormonal, and cytokine abnormalities, physical inactivity and direct effects of ethanol and its metabolites. New approaches to manage sarcopenia are being evolved. Branched chain amino acid supplementation, Myostatin inhibitors, and mitochondrial protective agents are currently in various stages of evaluation in preclinical studies to prevent and reverse sarcopenia, in cirrhosis.
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Key Words
- (PG) SGA, patient-generated SGA
- AMPK, 5′ adenosine monophosphate-activated protein kinase
- ASPEN, American Society of Parenteral and Enteral Nutrition
- ATP, adenosine triphosphate
- Akt/PKB, serine/threonine-specific protein kinase B
- BIA, bio-electric impedance analysis
- BMC, bone mineral content
- BMI, body mass index
- CT, computed tomography
- DDLT, deceased donor liver transplantation
- DRM, disease-related malnutrition
- DXA, dual X-ray absorptiometry
- ESPEN, European Society of Parenteral and Enteral Nutrition
- FFI, Fried Frailty Index
- FFM, fat free mass
- FFMI, fat free mass index
- FM, fat mass
- HE, hepatic encephalopathy
- LDLT, living donor liver transplant
- LST, lean soft tissue
- MAC, mid arm circumference
- MAMC, mid arm muscle circumference
- MELD, model for end-stage liver disease
- MNA, Mini Nutritional Assessment
- MRI, magnetic resonance imaging
- NASH, non-alcoholic steatohepatitis
- PCM, protein-calorie nalnutrition
- REE, resting energy expenditure
- RQ, respiratory quotient (or RQ or respiratory coefficient)
- SGA, Subjective Global Assessment
- SMI, Skeletal Muscle Index
- SPPB, Short Physical Performance Battery
- TIPS, trans jugular intrahepatic portocaval shunts
- TNF, tumour necrosis factor
- TSF, triceps skin fild thickness
- WHO, World Health Organisation
- YPA, total psoas area
- aKG, alfa keto glutarate
- cirrhosis
- mTORC1, mammalian target of rapamycin complex 1
- nutrition
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Walcott-Sapp S, Billingsley KG. Preoperative optimization for major hepatic resection. Langenbecks Arch Surg 2017; 403:23-35. [PMID: 29150719 DOI: 10.1007/s00423-017-1638-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 11/06/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE Major hepatic resections are performed for primary hepatobiliary malignancies, metastatic disease, and benign lesions. Patients with chronic liver disease, including cirrhosis and steatosis, are at an elevated risk of malnutrition and impaired strength and exercise capacity, deficits which cause increased risk of postoperative complications and mortality. The aims of this report are to discuss the pathophysiology of changes in nutrition, exercise capacity, and muscle strength in patient populations likely to require major hepatectomy, and review recommendations for preoperative evaluation and optimization. METHODS Nutritional and functional impairment in preoperative hepatectomy patients, especially those with underlying liver disease, have a complex and multifactorial physiologic basis that is not completely understood. RESULTS Recognition of malnutrition and compromised strength and exercise tolerance preoperatively can be difficult, but is critical in providing the opportunity to intervene prior to major hepatic resection and potentially improve postoperative outcomes. There is promising data on a variety of nutritional strategies to ensure adequate intake of calories, proteins, vitamins, and minerals in patients with cirrhosis and reduce liver size and degree of fatty infiltration in patients with hepatic steatosis. Emerging evidence supports structured exercise programs to improve exercise tolerance and counteract muscle wasting. CONCLUSIONS The importance of nutrition and functional status in patients indicated for major liver resection is apparent, and emerging evidence supports structured preoperative preparation programs involving nutritional intervention and exercise training. Further research is needed in this field to develop optimal protocols to evaluate and treat this heterogeneous cohort of patients.
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Affiliation(s)
- Sarah Walcott-Sapp
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Mail Code: L223, Portland, OR, 97239, USA.
| | - Kevin G Billingsley
- Division of Surgical Oncology, Department of Surgery, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Mail Code: L223, Portland, OR, 97239, USA
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42
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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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Abstract
Gastrointestinal (GI) complications of cirrhosis are frequent in patients who require intensive care support and are often the primary indication for intensive care unit (ICU) admission. Perhaps the most worrisome GI complication for the intensivist is variceal hemorrhage. Bleeding from esophageal or gastric varices represents a life-threatening event for cirrhotic patients and provides management challenges for the ICU team. Nonvariceal GI bleeding, impaired GI motility, and malnutrition also provide significant challenges for the intensivist. This article reviews GI issues that present in critically ill cirrhotic patients and their management in the acute setting.
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Affiliation(s)
- Jody C Olson
- The University of Kansas, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
| | - Kia Saeian
- Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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44
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Kappus MR, Mendoza MS, Nguyen D, Medici V, McClave SA. Sarcopenia in Patients with Chronic Liver Disease: Can It Be Altered by Diet and Exercise? Curr Gastroenterol Rep 2016; 18:43. [PMID: 27372291 DOI: 10.1007/s11894-016-0516-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Sarcopenia, a loss of muscle mass, is being increasingly recognized to have a deleterious effect on outcomes in patients with chronic liver disease. Factors related to diet and the inflammatory nature of chronic liver disease contribute to the occurrence of sarcopenia in these patients. Sarcopenia adversely influences quality of life, performance, morbidity, success of transplantation, and even mortality. Specific deficiencies in macronutrients (protein, polyunsaturated fatty acids) and micronutrients (vitamins C, D, and E, carotenoids, and selenium) have been linked to sarcopenia. Lessons learned from nutritional therapy in geriatric patient populations may provide strategies to manage sarcopenia in patients with liver disease. Combining diet modification and nutrient supplementation with an organized program of exercise may help ameliorate or even reverse the effects of sarcopenia on an already complex disease process.
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Affiliation(s)
- Matthew R Kappus
- Department of Medicine, Duke University Medical Center, DUMS 03142, Orange Zone, Durham, NC, 27710, USA.
| | | | - Douglas Nguyen
- Department of Medicine, College of Medicine, University of California-Irvine, Irvine, CA, USA
| | - Valentina Medici
- Department of Medicine, University of California-Davis, Davis, CA, USA
| | - Stephen A McClave
- Department of Medicine, School of Medicine, University of Louisville, Louisville, KY, USA
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Abstract
Lactic acidosis is an etiologically and biochemically heterogeneous disorder that is due to the overproduc tion of lactic acid or the underutilization of lactate. It occurs with disorders in which tissue oxygenation is impaired (Type A) and with disorders in which it is not (Type B). Lactic acidosis is an anion-gap metabolic acidosis in which the lactate concentration is greater than or equal to 5 mM and the systemic pH is less than 7.30. Treatment is largely empiric and generally unsatis factory. The use of sodium bicarbonate in lactic acidosis is currently controversial. The adverse effects of bicar bonate and the beneficial effects of dichloroacetate in experimental models of lactic acidosis are reviewed.
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Affiliation(s)
- Robert A. Kreisberg
- University of South Alabama College of Medicine, 2451 Fillingim St, Mobile, AL 36617
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46
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Montano-Loza AJ, Angulo P, Meza-Junco J, Prado CMM, Sawyer MB, Beaumont C, Esfandiari N, Ma M, Baracos VE. Sarcopenic obesity and myosteatosis are associated with higher mortality in patients with cirrhosis. J Cachexia Sarcopenia Muscle 2016; 7:126-35. [PMID: 27493866 PMCID: PMC4864157 DOI: 10.1002/jcsm.12039] [Citation(s) in RCA: 356] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/16/2015] [Accepted: 04/09/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND AIMS Obesity is frequently associated with cirrhosis, and cirrhotic patients may develop simultaneous loss of skeletal muscle and gain of adipose tissue, culminating in the condition of sarcopenic obesity. Additionally, muscle depletion is characterized by both a reduction in muscle size and increased proportion of muscular fat, termed myosteatosis. In this study, we aimed to establish the frequency and clinical significance of sarcopenia, sarcopenic obesity and myosteatosis in cirrhotic patients. METHODS We analysed 678 patients with cirrhosis. Sarcopenia, sarcopenic obesity and myosteatosis were analysed by CT scan using the third lumbar vertebrae skeletal muscle and attenuation indexes, using previously validated gender-and body mass index-specific cutoffs. RESULTS Patients were predominately men (n = 457, 67%), and cirrhosis aetiology was hepatitis C virus in 269 patients (40%), alcohol in 153 (23%), non-alcoholic steatohepatitis/cryptogenic in 96 (14%), autoimmune liver disease in 55 (8%), hepatitis B virus in 43 (6%), and others in 5 patients (1%). Sarcopenia was present in 292 (43%), 135 had sarcopenic obesity (20%) and 353 had myosteatosis (52%). Patients with sarcopenia (22 ± 3 vs. 95 ± 22 months, P < 0.001), sarcopenic obesity (22 ± 3 vs. 95 ± 22 months, P < 0.001), and myosteatosis (28 ± 5 vs. 95 ± 22 months, P < 0.001) had worse median survival than patients without muscular abnormalities. By multivariate Cox regression analysis, both sarcopenia [hazard ratio (HR) 2.00, 95% confidence interval (CI) 1.44-2.77, P < 0.001], and myosteatosis (HR 1.42, 95% CI 1.02-1.07, P = 0.04) were associated with mortality. CONCLUSIONS Sarcopenia, sarcopenic obesity and myosteatosis are often present in patients with cirrhosis, and sarcopenia and myosteatosis are independently associated with a higher long-term mortality in cirrhosis.
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Affiliation(s)
- Aldo J Montano-Loza
- Division of Gastroenterology & Liver Unit University of Alberta Hospital Edmonton Alberta Canada
| | - Paul Angulo
- Division of Digestive Diseases & Nutrition University of Kentucky Medical Center Lexington KY USA
| | - Judith Meza-Junco
- Department of Oncology Cross Cancer Institute Edmonton Alberta Canada
| | - Carla M M Prado
- Department of Agricultural Food and Nutritional Sciences Edmonton Alberta Canada
| | - Michael B Sawyer
- Department of Oncology Cross Cancer Institute Edmonton Alberta Canada
| | - Crystal Beaumont
- Department of Oncology Cross Cancer Institute Edmonton Alberta Canada
| | - Nina Esfandiari
- Department of Oncology Cross Cancer Institute Edmonton Alberta Canada
| | - Mang Ma
- Division of Gastroenterology & Liver Unit University of Alberta Hospital Edmonton Alberta Canada
| | - Vickie E Baracos
- Department of Oncology Cross Cancer Institute Edmonton Alberta Canada
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47
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Hyötyläinen T, Jerby L, Petäjä EM, Mattila I, Jäntti S, Auvinen P, Gastaldelli A, Yki-Järvinen H, Ruppin E, Orešič M. Genome-scale study reveals reduced metabolic adaptability in patients with non-alcoholic fatty liver disease. Nat Commun 2016; 7:8994. [PMID: 26839171 DOI: 10.1038/ncomms9994] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 10/22/2015] [Indexed: 12/14/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a major risk factor leading to chronic liver disease and type 2 diabetes. Here we chart liver metabolic activity and functionality in NAFLD by integrating global transcriptomic data, from human liver biopsies, and metabolic flux data, measured across the human splanchnic vascular bed, within a genome-scale model of human metabolism. We show that an increased amount of liver fat induces mitochondrial metabolism, lipolysis, glyceroneogenesis and a switch from lactate to glycerol as substrate for gluconeogenesis, indicating an intricate balance of exacerbated opposite metabolic processes in glycemic regulation. These changes were associated with reduced metabolic adaptability on a network level in the sense that liver fat accumulation puts increasing demands on the liver to adaptively regulate metabolic responses to maintain basic liver functions. We propose that failure to meet excessive metabolic challenges coupled with reduced metabolic adaptability may lead to a vicious pathogenic cycle leading to the co-morbidities of NAFLD.
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Affiliation(s)
- Tuulia Hyötyläinen
- Department of Systems Medicine, Steno Diabetes Center, Niels Steensens Vej 6, Gentofte, DK-2820, Denmark.,VTT Technical Research Centre of Finland, Espoo, FI-02044 VTT, Finland
| | - Livnat Jerby
- Blavatnik School of Computer Science, Tel Aviv University, Tel Aviv 69978, Israel
| | - Elina M Petäjä
- Department of Medicine, Division of Diabetes, University of Helsinki, Helsinki, FI-00014, Finland.,Minerva Foundation Institute for Medical Research, Helsinki FI-00290, Finland
| | - Ismo Mattila
- Department of Systems Medicine, Steno Diabetes Center, Niels Steensens Vej 6, Gentofte, DK-2820, Denmark.,VTT Technical Research Centre of Finland, Espoo, FI-02044 VTT, Finland
| | - Sirkku Jäntti
- VTT Technical Research Centre of Finland, Espoo, FI-02044 VTT, Finland.,Faculty of Pharmacy, University of Helsinki, Helsinki FI-00014, Finland
| | - Petri Auvinen
- Institute of Biotechnology, DNA Sequencing and Genomics Laboratory, University of Helsinki, Helsinki FI-00014, Finland
| | - Amalia Gastaldelli
- Institute of Clinical Physiology, National Research Council, Pisa 56124, Italy
| | - Hannele Yki-Järvinen
- Department of Medicine, Division of Diabetes, University of Helsinki, Helsinki, FI-00014, Finland.,Minerva Foundation Institute for Medical Research, Helsinki FI-00290, Finland
| | - Eytan Ruppin
- Blavatnik School of Computer Science, Tel Aviv University, Tel Aviv 69978, Israel.,Center for BioInformatics and Computational Biology, Department of Computer Science, University of Maryland, College Park, Maryland 20742, USA
| | - Matej Orešič
- Department of Systems Medicine, Steno Diabetes Center, Niels Steensens Vej 6, Gentofte, DK-2820, Denmark.,VTT Technical Research Centre of Finland, Espoo, FI-02044 VTT, Finland.,Turku Centre for Biotechnology, University of Turku and Åbo Akademi University, Turku FI-20520, Finland
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48
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Abstract
As many as 80% of patients with end-stage liver disease and hepatic encephalopathy have significant protein-calorie malnutrition. Because of the severe hypercatabolic state of cirrhosis, the provision of liberal amounts of carbohydrate (at least 35 to 40 kcal/kg per day), and between 1.2 and 1.6 g/kg of protein is necessary. Protein restriction is not recommended. Branched-chain amino acid supplementation and vegetable protein are associated with improved outcomes. Dietary supplementation with vitamins, minerals (with the notable exception of zinc) and probiotics should be decided on a case-by-case basis.
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49
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Two randomized controlled studies comparing the nutritional benefits of branched-chain amino acid (BCAA) granules and a BCAA-enriched nutrient mixture for patients with esophageal varices after endoscopic treatment. J Gastroenterol 2015; 50:109-18. [PMID: 24633624 PMCID: PMC4286625 DOI: 10.1007/s00535-014-0950-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 02/23/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND The usefulness of branched-chain amino acid (BCAA) granules and BCAA-enriched nutrient mixtures for patients with liver cirrhosis is often reported. However, no randomized controlled studies have investigated the usefulness of these supplements in the nutritional intervention of cirrhotic patients receiving endoscopic treatment for esophageal varices. METHODS Patients without BCAA before endoscopic treatment were divided into study 1, and those who received BCAA were divided into study 2. In study 1, 44 eligible patients were divided into a control group (n = 13), a general liquid nutrient (snack) group (n = 15), and a BCAA-enriched nutrient mixture (BCAA-EN) group (n = 16). In study 2, 48 eligible patients were divided into a BCAA group (n = 24) and a BCAA-EN group (n = 24). The nutritional status including non-protein respiratory quotient (NPRQ) levels, weight gain, and albumin were evaluated on days 0, 7, and 50. RESULTS In study 1, the BCAA-EN group showed significant improvement in NPRQ levels on day 7 as compared with the snack group. In study 2, the BCAA-EN group showed significant improvement in NPRQ levels on day 7 and in weight levels on day 50 relative to the BCAA group, while the BCAA group showed improved serum albumin levels on day 7 compared to the BCAA-EN group. CONCLUSIONS The BCAA-enriched nutrient mixture maintained NPRQ and weight in cirrhotic patients. Our findings suggest that supplements including both BCAA and a nutritional energy supplement would be beneficial for cirrhotic patients undergoing endoscopic treatment for esophageal varices.
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50
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Holecek M. Ammonia and amino acid profiles in liver cirrhosis: Effects of variables leading to hepatic encephalopathy. Nutrition 2015; 31:14-20. [DOI: 10.1016/j.nut.2014.03.016] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 03/20/2014] [Accepted: 03/23/2014] [Indexed: 02/07/2023]
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