Glucose intolerance in liver cirrhosis: role of hepatic and non-hepatic influences

Intermittent fasting and the liver: Focus on the Ramadan model

Intermittent fasting (IF) is an intervention that involves not only dietary modifications but also behavioral changes with the main core being a period of fasting alternating with a period of controlled feeding. The duration of fasting differs from one regimen to another. Ramadan fasting (RF) is a religious fasting for Muslims, it lasts for only one month every one lunar year. In this model of fasting, observers abstain from food and water for a period that extends from dawn to sunset. The period of daily fasting is variable (12-18 hours) as Ramadan rotates in all seasons of the year. Consequently, longer duration of daily fasting is observed during the summer. In fact, RF is a peculiar type of IF. It is a dry IF as no water is allowed during the fasting hours, also there are no calorie restrictions during feeding hours, and the mealtime is exclusively nighttime. These three variables of the RF model are believed to have a variable impact on different liver diseases. RF was evaluated by different observational and interventional studies among patients with non-alcoholic fatty liver disease and it was associated with improvements in anthropometric measures, metabolic profile, and liver biochemistry regardless of the calorie restriction among lean and obese patients. The situation is rather different for patients with liver cirrhosis. RF was associated with adverse events among patients with liver cirrhosis irrespective of the underlying etiology of cirrhosis. Cirrhotic patients developed new ascites, ascites were increased, had higher serum bilirubin levels after Ramadan, and frequently developed hepatic encephalopathy and acute upper gastrointestinal bleeding. These complications were higher among patients with Child class B and C cirrhosis, and some fatalities occurred due to fasting. Liver transplant recipients as a special group of patients, are vulnerable to dehydration, fluctuation in blood immunosuppressive levels, likelihood of deterioration and hence observing RF without special precautions could represent a real danger for them. Patients with Gilbert syndrome can safely observe RF despite the minor elevations in serum bilirubin reported during the early days of fasting.

ESPEN practical guideline: Clinical nutrition in liver disease

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.

Prevalence and Association of Elevated Liver Transaminases in Type 2 Diabetes Mellitus Patients in Jeddah, Saudi Arabia

Background This study investigated the prevalence and association of liver transaminases in type 2 diabetes mellitus (T2DM) patients at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. Methods This retrospective, cross-sectional study was carried out on 211 T2DM patients at KAUH in 2017, and the Research Ethics Committee of KAUH approved this study. The data were analyzed on SPSS 21 (IBM Corp., Armonk, NY, US). The association of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) with several risk factors was computed by the chi-square test. The odds ratio with a 95% confidence interval (CI) was also calculated. Results The mean age of study participants was 60 ± 13.43 years; 143 (67.8%) were female while 68 (32.2%) were male. Serum AST levels were elevated in 6.16% (10.3% in males, 4.2% in females). Elevated ALT levels were found in 7.58% (11.8% in males, 5.6% in females) (Table 2). The probability of rising AST levels increased with age (OR = 2.59 for patients aged 46-65) and with male gender (OR = 2.65, CI: 0.84-8.12). Additionally, the probability of rising ALT levels increased with male gender (OR = 2.25, CI: 0.80-6.27), low-density lipoproteins (LDL-C) (OR = 2.11, CI: 0.73-6.04), and triglycerides (TG) (OR = 2.08, CI: 0.739-5.87). No statistically noteworthy association was observed between elevated levels of AST and ALT with gender, age, body mass index (BMI), glycated hemoglobin (HbA1c), TG, total cholesterol (TC), LDL-C, and high-density lipoprotein cholesterol (HDL-C) levels, smoking, or hypertension. Conclusion Higher ALT and AST levels were found in T2DM patients but with no statistically significant link between elevated levels and gender, age, BMI, HbA1c, TG, TC, HDL-C, LDL-C, smoking, or hypertension.

Significant effects of late evening snack on liver functions in patients with liver cirrhosis: A meta-analysis of randomized controlled trials

BACKGROUND AND AIM

Reducing post-absorptive (fasting) phase by eating late evening snacks (LESs) is a potential intervention to improve substrate utilization and reverse sarcopenia. This study analyzed the results of published randomized controlled trials and controlled clinical trials to evaluate the effects of LES on liver function of patients with cirrhosis.

METHODS

A meta-analysis was conducted. The search strategy included electronic database searches, and 300 articles were searched. Eight of these articles provided qualified data for pooling and analysis. Outcomes assessments included serum albumin, total bilirubin, alanine aminotransferase, prothrombin time, and aspartate aminotransferase, complications of cirrhosis, severity of liver disease, and blood glucose levels.

RESULTS

Our analysis included eight studies comprising 341 patients (167 in LES groups and 174 in control groups). The results showed that LES intervention helped to maintain liver reserves. These eight studies demonstrated that LES intervention had significant effects for liver biochemical parameters on albumin, ammonia, and prothrombin time, with respective effect sizes of 0.233, -0.425, and -0.589; liver enzymes include aspartate aminotransferase and alanine aminotransferase, with respective effect sizes of -0.320 and -0.284. Studies on clinical signs of liver dysfunction showed lower occurrence rates of ascites and hepatic encephalopathy than in the control group. LES had no significant effect on Child-Pugh score.

CONCLUSIONS

The overall results of the meta-analysis indicated that having LES can improve liver function reserve for patients with liver cirrhosis, with or without hepatocellular carcinoma. LES is a promising intervention for reversing anabolic resistance and the sarcopenia of cirrhosis, resulting in an improved quality of life for patients with cirrhosis.

Hepatitis C Direct Acting Antivirals and Ribavirin Modify Lipid but not Glucose Parameters

Chronic hepatitis C (HCV) infection perturbs lipid and glucose metabolism. The influence of direct acting antiviral (DAA) treatment and ribavirin on these measures was evaluated. Furthermore, the effect of HCV cure on these parameters was assessed. Participants were allocated to one of three 12-week treatment groups: non-cirrhotic genotype 1a-paritaprevir/ritonavir/ombitasvir/dasabuvir (PrOD) plus ribavirin; non-cirrhotic 1b-PrOD; compensated cirrhotic 1a or 1b-PrOD plus ribavirin. Fasting insulin, glucose, lipid and apolipoprotein measures were assessed at baseline, Treatment Weeks 4 and 12, and 12 and 24 weeks post-dosing. Twenty-three of 24 participants achieved SVR (PP= 23/24, 96% SVR). Overall, total cholesterol, low-density lipoprotein cholesterol (LDL-C), and triglyceride levels all increased in treatment and post-dosing. However, LDL-C levels decreased during treatment in ribavirin recipients. Fasting glucose, insulin, and HOMA-IR were unchanged during treatment and 12 weeks post-treatment. By 12 weeks post-treatment, controlled attenuation parameter (CAP) scores, a measure of steatosis, increased from baseline (mean 30.3 ± 63.5, p = 0.05). This regimen was safe and highly effective and did not influence glucose metabolism. Ribavirin exposure may mitigate some on-treatment lipid changes. Further mechanistic studies are needed to understand how ribavirin impacts lipid pathways, as there could be therapeutic implications. The metabolic pathophysiology of increased CAP score with HCV treatment requires explanation.

ESPEN guideline on clinical nutrition in liver disease

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.

Hepatogenous Diabetes: An Underestimated Problem of Liver Cirrhosis

The prevalence of diabetes mellitus in cirrhotic patients is much higher than that in the general population. Two types of diabetes are usually seen in patients with cirrhosis: type 2 diabetes mellitus and hepatogenous diabetes (HD). The HD is an acquired condition which is believed to be caused by impaired insulin clearance and pancreatic β-cell dysfunction in cirrhotic patients. Increased levels of advanced glycation end products and hypoxia-inducible factors have been implicated in the pathogenesis of HD. Patients with HD typically present with normal fasting glucose, but abnormal response to an oral glucose tolerance test, which is required for the diagnosis. Because the level of glycated hemoglobin is often falsely low in patients with cirrhosis, it does not help in the early diagnosis of HD. HD is associated with an increased rate of complications of cirrhosis, decreased 5-year survival rate, and increased risk of hepatocellular carcinoma. The major complications of cirrhosis associated with HD include hepatic encephalopathy (HE), spontaneous bacterial peritonitis, sepsis, variceal hemorrhage, and renal dysfunction. Treatment of HD may be difficult as many antihyperglycemic therapies are associated with increased risk of complications in cirrhosis, particularly hypoglycemia. Biguanides, alpha-glucosidase inhibitors, and new medications such as dipeptidyl peptidase-4 inhibitors and sodium-glucose co-transporter 2 inhibitors appear to be safe in patients with cirrhosis. Though insulin therapy is currently advocated, requirement of insulin is variable and is difficult to predict. The liver transplantation usually results in reversal of HD. This review article provides an overview of magnitude, patients' characteristics, clinical implications, pathophysiological mechanisms, diagnosis, and management of HD.

Verification of glycemic profiles using continuous glucose monitoring: cases with steroid use, liver cirrhosis, enteral nutrition, or late dumping syndrome

Glycemic control is often difficult to achieve in patients with diabetes, especially in the presence of comorbid diseases or conditions such as steroid-use or liver cirrhosis, or in patients receiving enteral nutrition. Moreover, reactive hypoglycemia due to late dumping syndrome in people having undergone gastrectomy is also a matter of concern. Empirically and theoretically, the typical glycemic profiles associated with these conditions have been determined; however, what actually happens during a 24-h span is still somewhat obscure. In order to verify and provide information about the 24-h glycemic profiles associated with these conditions, 8 patients with the 4 above-mentioned conditions were monitored using a continuous glucose monitoring system (CGMS). For all 8 patients, CGMS provided detailed information regarding the 24-h glycemic profiles. The CGM results showed typical glycemic patterns for each condition, and we were moreover able to observe the effects of various practical treatments. Based on these cases, we conclude that the CGMS is highly useful for determining the glycemic patterns of patients with the aforementioned conditions in a practical setting; and this system may be used to monitor the treatment success of such cases.

Insulin resistance as early sign of hepatic dysfunction in liver cirrhosis

Glucose intolerance characterized by postprandial hyperglycemia and hyperinsulinemia is commonly seen in patients with liver cirrhosis (LC). The aim of this study is to clarify the relation between glucose intolerance and disorder of liver function in patients with LC. The 75 g oral glucose tolerance test (75 g OGTT) and the hyperinsulinemic euglycemic clamp combined with 0.2 g/kg oral glucose load (HECGL) were conducted in 61 patients with LC. Based on the results of 75 g OGTT, the 61 patients with LC were divided into groups, 21 (34.4%) patients with normal glucose tolerance (LC-NGT), 12 (19.7%) patients with impaired glucose tolerance (LC-IGT) and 28 (45.9%) patients with diabetes mellitus (LC-DM). Fasting plasma glucose (FPG) level was normal in 50 (82.0%) patients with LC. All patients with LC showed insulin resistance in both peripheral (skeletal and adipose) and hepatic tissues evaluated by HECGL, although significant correlation between the degree of glucose intolerance and the severity of hepatic dysfunction was not observed. Insulin resistance in both liver and peripheral tissues is the early sign in the patients with LC. This fact indicates that nutritional care from early stages of LC would be necessary in the patients.

Hepatology - Guidelines on Parenteral Nutrition, Chapter 16

Parenteral nutrition (PN) is indicated in alcoholic steatohepatitis (ASH) and in cirrhotic patients with moderate or severe malnutrition. PN should be started immediately when sufficientl oral or enteral feeding is not possible. ASH and cirrhosis patients who can be sufficiently fed either orally or enterally, but who have to abstain from food over a period of more than 12 hours (including nocturnal fasting) should receive basal glucose infusion (2–3 g/kg/d). Total PN is required if such fasting periods last longer than 72 h. PN in patients with higher-grade hepatic encephalopathy (HE); particularly in HE IV° with malfunction of swallowing and cough reflexes, and unprotected airways. Cirrhotic patients or patients after liver transplantation should receive early postoperative PN after surgery if they cannot be sufficiently rally or enterally nourished. No recommendation can be made on donor or organ conditioning by parenteral administration of glutamine and arginine, aiming at minimising ischemia/reperfusion damage. In acute liver failure artificial nutrition should be considered irrespective of the nutritional state and should be commenced when oral nutrition cannot be restarted within 5 to 7 days. Whenever feasible, enteral nutrition should be administered via a nasoduodenal feeding tube.

Occurrence of hepatitis C virus infection in type 2 diabetic patients attending Plateau state specialist hospital Jos Nigeria

BACKGROUND

Glucose intolerance is observed more in patients with HCV infection compared with control subjects with liver disease, Initial studies suggested that Hepatitis C virus infection may be an additional risk factor for the development of diabetes mellitus. This study was therefore carried out to determine the correlation of HCV infection and diabetes.

METHODS

Three hundred (300) confirmed type 2 diabetic patients were screened for hepatitis C virus antibodies at the Plateau state specialist hospital, Jos, using Grand diagnostic test strip. Questionnaire comprising of age, sex, family history on diabetes, duration of disease and marital status were issued to subjects.

RESULTS

Overall result showed that the prevalence rate of HCV infection was 33(11%). In response to diabetic status, females subjects had a higher prevalence of 178(59.3%) compared to males 122(40.7%). Those aged 47-57 recorded the highest seroprevalence 10(30.3%) to the Hepatitis C Virus, while Patients without family history of diabetes showed a higher seroprevalence of 13(39.4%). Subjects who never had any blood transfusion recorded a prevalence rate of 6(18.2%). Marital status showed no significant difference [(P = 0.275; P.0.05)]. Considering duration of developing diabetes, patients within the range of 1-10 years diabetic status recorded the highest prevalence rate 25(75.8%) compared to other ranges considered.

CONCLUSION

This study hence, suggests a relatively strong association between HCV infection and diabetes, this therefore call for an urgent approach strategy in the control and management of this disease of the endocrine system.

Prevalence and determinants of diabetes mellitus among Iranian patients with chronic liver disease

BACKGROUND: Alterations in carbohydrate metabolism are frequently observed in cirrhosis. We conducted this study to define the prevalence of diabetes mellitus (DM) and impaired glucose tolerance (IGT) in Iranian patients with chronic liver disease (CLD), and explore the factors associated with DM in these patients. METHODS: One hundred and eighty-five patients with CLD were enrolled into the study. Fasting plasma glucose and two-hour plasma glucose were measured in patients' sera. DM and IGT were diagnosed according to the latest American Diabetes Association criteria. RESULTS: The subjects included 42 inactive HBV carriers with a mean age of 42.2 +/- 12.0 years, 102 patients with HBV or HCV chronic hepatitis with a mean age of 41.2 +/- 10.9 years, and 41 cirrhotic patients with a mean age of 52.1 +/- 11.4 years. DM and IGT were diagnosed in 40 (21.6%) and 21 (11.4%) patients, respectively. Univariate analysis showed that age (P = 0.000), CLD status (P = 0.000), history of hypertension (P = 0.007), family history of DM (P = 0.000), and body mass index (BMI) (P = 0.009) were associated with DM. Using Multivariate analysis, age (OR = 4.7, 95%CI: 1.8-12.2), family history of DM (OR = 6.6, 95%CI: 2.6-17.6), chronic hepatitis (OR = 11.6, 95%CI: 2.9-45.4), and cirrhosis (OR = 6.5, 95%CI: 2.4-17.4) remained as the factors independently associated with DM. When patients with cirrhosis and chronic hepatitis were analyzed separately, higher Child-Pugh's score in cirrhotic patients (OR = 9.6, 95%CI: 1.0-88.4) and older age (OR = 7.2, 95%CI: 1.0-49.1), higher fibrosis score (OR = 59.5, 95%CI: 2.9-1211.3/ OR = 11.9, 95%CI: 1.0-132.2), and higher BMI (OR = 30.3, 95%CI: 3.0-306.7) in patients with chronic hepatitis were found to be associated with higher prevalence of DM. CONCLUSIONS: Our findings indicate that patients with cirrhosis and chronic hepatitis are at the increased risk of DM occurrence. Older age, severe liver disease, and obesity were associated with DM in these patients.

Different degrees of malnutrition and immunological alterations according to the aetiology of cirrhosis: a prospective and sequential study

OBJECTIVES

In this work we investigated how immunological dysfunction and malnutrition interact in alcoholic and viral aetiologies of cirrhosis.

METHODS

To investigate the matter, 77 cirrhotic patients divided in three aetiologies [Alcohol, HCV and Alcohol + HCV) and 32 controls were prospectivelly and sequentially studied. Parameters of humoral immunity (Components 3 and 4 of seric complement and immunoglobulins A M, G and E) and of cellular immunity (total leukocytes and lymphocytes in peripheral blood, T lymphocytes subpopulations, CD4+ and CD8+, CD4+/CD8+ ratio and intradermic tests of delayed hypersensitivity), as well as nutritional parameters: anthropometric measures, serum albumin and transferrin were evaluated.

RESULTS

Multiple statistical comparisons showed that IgM was higher in HCV group; IgG was significantly elevated in both HCV and Alcohol + HCV, whereas for the Alcohol group, IgE was found at higher titles. The analysis of T- lymphocytes subpopulations showed no aetiologic differences, but intradermic tests of delayed hypersensitivity did show greater frequency of anergy in the Alcohol group. For anthropometric parameters, the Alcohol +HCV group displayed the lowest triceps skinfold whereas creatinine--height index evaluation was more preserved in the HCV group. Body mass index, arm muscle area and arm fat area showed that differently from alcohol group, the HCV group was similar to control.

CONCLUSION

Significant differences were found among the main aetiologies of cirrhosis concerning immunological alterations and nutritional status: better nutrition and worse immunology for HCV and vice-versa for alcohol.

Nutrition in hepatic failure and liver transplantation

Protein-energy malnutrition (PEM) is a common problem in patients with end-stage liver disease, and it is universally present in patients undergoing orthotopic liver transplantation. Although PEM is an independent risk factor for morbidity and mortality, it need not be considered an absolute contraindication for liver transplantation. The etiology of PEM in liver disease is multifactorial and includes decreased nutrient and calorie intake, alterations in intestinal malabsorption and/or maldigestion, and diverse abnormalities of carbohydrate, fat, and protein metabolism. This article reviews the prevalence of malnutrition, its pathophysiology, different modalities for assessment of body composition, and general guidelines for nutritional support in patients with liver disease and liver transplantation.