Nutritional Support for Liver Diseases

The liver is a key organ that is responsible for the metabolism of proteins, fats, and carbohydrates and the absorption and storage of micronutrients. Unfortunately, the prevalence of chronic liver diseases at various stages of advancement in the world population is significant. Due to the physiological function of the liver, its dysfunction can lead to malnutrition and sarcopenia, and the patient's nutritional status is an important prognostic factor. This review discusses key issues related to the diet therapy of patients with chronic liver diseases, as well as those qualified for liver transplantation and in the postoperative period.

Preoperative Oral Carbohydrate (CHO) Supplementation Is Beneficial for Clinical and Biochemical Outcomes in Patients Undergoing Elective Cesarean Delivery under Spinal Anaesthesia-A Randomized Controlled Trial

BACKGROUND

Preoperative fasting and surgery cause metabolic stress, insulin resistance with ketosis, and postoperative nausea and vomiting (PONV). Oral carbohydrate loading strategy (CHO) improves outcomes in labor and general surgery. We aimed to compare the effectiveness of CHO with standard fasting in patients undergoing elective cesarean delivery (CD) under spinal anesthesia.

METHODS

A single-center, parallel, prospective randomized controlled trial (RCT) was conducted in a tertiary university obstetrics department at Pomeranian Medical University in Szczecin, Poland. Patients were randomly assigned (1:1 ratio) to the CHO group (oral carbohydrate 2 h before elective CD, n = 75) or the SF group (control-standard fasting, n = 73). The main outcome measures were incidence and severity of PONV at 6 and 24 h after CD, time to the first peristalsis, time to first bowel movement, and biochemical parameters indicating ketosis in mothers and their children.

RESULTS

A total of 148 adult females with singleton pregnancies undergoing elective CD under spinal anesthesia (ASA I and II) were included in the final analysis. At 24 h after CD, 8.0% from the CHO group vs. 20.55% reported three or more episodes of vomiting or dry retching as compared to patients in the SF group (p = 0.041). Preoperative CHO supplementation decreased preoperative feelings of hunger (p < 0.001) and thirst (p < 0.001). Laboratory results in the CHO group showed higher plasma pH (p = 0.001) and glucose (p < 0.001), lower F2-isoprostane in plasma (p = 0.049) and urine (p = 0.018), lower urine F2-isoprostane/creatinine ratio (p = 0.045) than in the SF group. HOMA-IR (p < 0.001) and lactate (p < 0.001) were higher in the CHO group than in the control group.

CONCLUSIONS

There was no significant difference in the incidence or severity of early PONV at 6 h. The incidence of vomiting or dry retching at 24 h after cesarean delivery was lower in the CHO group as compared to standard starvation, but the combined results of PONV frequency and severity on the Wengritzky scale did not differ between the two study groups. Preoperative CHO supplementation decreased preoperative feelings of hunger and thirst, enhancing the comfort of pregnant women.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04069806.

The Prevalence of Small Intestinal Bacterial Overgrowth in Patients with Non-Alcoholic Liver Diseases: NAFLD, NASH, Fibrosis, Cirrhosis-A Systematic Review, Meta-Analysis and Meta-Regression

Bacterial overgrowth in the small intestine (SIBO) is a pathological growth of the intestinal microbiota in the small intestine that causes clinical symptoms and can lead to digestive and absorption disorders. There is increasing evidence that people with NAFLD have a distinct gut microflora profile as well metabolome changes compared to people without NAFLD. Thorough analysis of observational and RCT studies in the current databases (EMBASE, Web of Science, PubMed, Cinahl, Clinical Trials) was conducted from 3 November 2021 to 21 June 2022. The following inclusion criteria were applied: confirmed NAFLD, NASH, LIVER FIBROSIS, CIRRHOSIS due to steatosis; diagnostic methods of liver diseases—biopsy, elastography, transabdominal ultrasound; nonalcoholic fatty liver disease activity score; confirmed SIBO; diagnostic methods of SIBO−breath tests (hydrogen test; methane test and mix test; duodenal and jejunal aspiration before any type of intervention; adults above 18yo; number of participants ≥20; full articles. We excluded review articles, populations with HBV/HCV infection and alcohol etiology and interventions that may affect NAFLD or SIBO treatment. The quality of each study methodology was classified by means of the Cochrane Collaboration’s tool (RCT) and Newcastle—Ottawa Quality Assessment Scale adapted for cross-sectional, cohort and case-control studies. The random effects meta-analysis of outcomes for which ≥2 studies contributed data was conducted. The I2 index to measure heterogeneity and the χ2 test of homogeneity (statistically significant heterogeneity p < 0.05) were applied. For categorical outcome, the pooled event rate (effect size) was calculated. This systematic review was reported according to PRISMA reporting guidelines. We initially identified 6643 studies, from which 18 studies were included in final meta-analysis. The total number of patients was 1263. Accepted SIBO diagnostic methods were both available breath tests (n-total = 15) and aspirate culture (n-total = 3). We found that among patients with non-alcoholic liver diseases, the random overall event rate of SIBO was 0.350 (95% CI, 0.244−0.472), p = 0.017. The subgroup analysis regarding a type of diagnosis revealed that the lowest ER was among patients who developed simultaneously NAFLD, NASH and fibrosis: 0.197 (95% CI, 0.054−0.510) as compared to other annotated subgroups. The highest prevalence of SIBO was observed in the NASH subgroup: 0.411 (95% CI, 0.219−0.634). There were no statistically significant differences in the prevalence of SIBO in different subgroups (p = 0.854). Statistically significant heterogeneity between studies was estimated (I2 = 86.17%, p = 0.00). Egger’s test did not indicate a publication bias (df = 16, p = 0.885). A meta-regression using a random-effects model revealed that higher percentage of males in the population with liver diseases is a predisposing factor toward SIBO (Q = 4.11, df = 1, p = 0.0426 with coefficient = 0.0195, SE = 0.0096, Z = 2.03). We showed that the prevalence of SIBO in patients with chronic non-alcoholic liver diseases can be as high as 35%, and it increases with the percentage of men in the population. The prevalence of SIBO does not differ significantly depending on the type of chronic liver disease. Despite the high heterogeneity and moderate and low quality of included studies, our meta-analysis suggests the existence of a problem of SIBO in the population of patients with non-alcoholic liver diseases, and the presence of SIBO, in turn, determines the therapeutic treatment of such type of patients, which indicates the need for further research in this area. The study protocol was registered with the international Prospective Register of Systematic Reviews (PROSPERO ID: CRD42022341473).

Tactile Processing and Quality of Sleep in Autism Spectrum Disorders

Individuals with autism spectrum disorders (ASDs) commonly experience problems with the processing of tactile stimuli and poor quality of sleep. The aim of the present study was to analyze whether tactile stimuli modulation (TSM) disorders might be linked to insomnia prevalence in ASD individuals. We hypothesized that sleep disorders in children with ASD may result from improper tactile under/over responsivity. The study included 27 children diagnosed with ASD, aged 6.8 (±2.9 years) with male dominance (n = 22, 81.5%). To evaluate the pattern of TSM we used a clinical interview with a parent, and guided and spontaneous observation of the patients. Sleep disorders were diagnosed using the Athens Insomnia Scale. Of all the children diagnosed with TSM, 20 patients (74.1%) had an over-responsivity pattern and 7 children (25.9%) had an under-responsivity pattern. Of the patients, 11 children (40.7%) met the diagnostic criteria for insomnia. The data indicated a statistical tendency for higher prevalence of insomnia in individuals diagnosed with tactile under-responsivity (p = 0.051). We concluded that under-responsivity toward tactile stimuli may be partly responsible for poor sleep quality in ASD. There is an urgent need to treat sleep and sensory disruptions which may intensify behavioral difficulties in ASD.

Gut microbiota and its metabolic potential

OBJECTIVE

The incidence of obesity and other metabolic-related diseases has been gradually increasing. Multiple genetic as well as environmental factors play a significant role in the pathogenesis of these entities. Currently, the involvement of gut microbiota in metabolic processes has been acknowledged. This paper focuses on obesity, type 2 diabetes, and nonalcoholic fatty liver disease regarding their link with microbiome structure and its function.

MATERIALS AND METHODS

We analyzed literature available in PubMed, Embase, and Google Scholar databases regarding a linkage of metabolic-associated diseases and gut microbiota RESULTS: Gut microbiota plays a significant role in host metabolism. Depending on its composition; however, it may contribute to the development of metabolic-associated diseases. In this context, not only composition of gut microbiota is important, but also its activity. Short-chain fatty acids or lipopolysaccharides are crucial metabolites involved in maintaining metabolic balance.

CONCLUSIONS

Gut microbiota malfunctions might potentially induce obesity, type 2 diabetes, and nonalcoholic fatty liver disease.

Reply to: "Preoperative Carbohydrate Loading on Outcomes after Cardiac Surgery: A Flawed Meta-Analysis. Comment on: The Effect of Preoperative Carbohydrate Loading on Clinical and Biochemical Outcomes after Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Trials. Nutrients 2020, 12, 3904"

We appreciate the thoughts and questions posed by Drs Dileep N Lobo and Girish P Joshi [...].

The Effect of Preoperative Carbohydrate Loading on Clinical and Biochemical Outcomes after Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Trials

Background and aim: Preoperative fasting leads to metabolic stress and causes insulin resistance in patients undergoing cardiac surgery. The aim of this study was to assess the effect of preoperative oral carbohydrate loading (OCH) on outcome in patients undergoing planned cardiac surgery by systematically reviewing the literature and synthesizing evidence from randomized controlled trials (RCTs). Methods: Systematic search of PubMed/MEDLINE/Embase/Cinahl/Web of Science/ClinicalTrials databases was performed to identify relevant RCTs from databased inception until 05/03/2020. We included studies that compared outcome measures between OCH with control (placebo or standard starvation). We conducted a random-effect meta-analysis of clinical and biochemical parameters. Results: Nine studies (N = 9) were included with a total of 507 patients. OCH significantly decreased aortic clamping duration (n = 151, standardized mean difference (SMD) = −0.28, 95% confidence interval (CI) = −0.521 to −0.038, p = 0.023 and differences in means (DM) = −6.388, 95%CI = −11.246 to −1.529, p = 0.010). Patients from treatment groups had shorter intensive care unit (ICU) stay (n = 202, SMD = −0.542, 95%CI = −0.789 to −0.295, p < 0.001 and DM = −25.925, 95%CI = −44.568 to −7.283, p = 0.006) and required fewer units of insulin postoperatively (n = 85, SMD = −0.349, 95%CI = −0.653 to −0.044, p = 0.025 and DM = −4.523, 95%CI = −8.417 to −0.630, p = 0.023). The necessity to use inotropic drugs was significantly lower in the OCH group (risk ratio (RR) = 0.795, 95%CI = 0.689 to 0.919, p = 0.002). All other primary outcomes did not reveal a significant effect. Conclusions: Preoperative OCH in patients undergoing cardiac surgery demonstrated a 20% reduction in the use of inotropic drugs, a 50% reduction of the length of ICU stay, a 28% decrease in aortic clamping duration and a 35% decrease of postoperative insulin requirement.

Nutritional Support in Coronavirus 2019 Disease

The epidemic that broke out in Chinese Wuhan at the beginning of 2020 presented how important the rapid diagnosis of malnutrition (elevating during intensive care unit stay) and the immediate implementation of caloric and protein-balanced nutrition care are. According to specialists from the Chinese Medical Association for Parenteral and Enteral Nutrition (CSPEN), these activities are crucial for both the therapy success and reduction of mortality rates. The Chinese have published their recommendations including principles for the diagnosis of nutritional status along with the optimal method for nutrition supply including guidelines when to introduce education approach, oral nutritional supplement, tube feeding, and parenteral nutrition. They also calculated energy demand and gave their opinion on proper monitoring and supplementation of immuno-nutrients, fluids and macronutrients intake. The present review summarizes Chinese observations and compares these with the latest European Society for Clinical Nutrition and Metabolism guidelines. Nutritional approach should be an inseparable element of therapy in patients with COVID-19.

Body Weight Reduction and Biochemical Parameters of the Patients After RYGB and SG Bariatric Procedures in 12-Month Observation

Background

The aim of this study was to evaluate the effect of sleeve gastrectomy (SG) and Roux-en-Y-bypass (RYGB) on anthropometric and biochemical parameters, including changes in glucose levels, lipid profile and liver function. Drastic decrease in all lipid fractions a few weeks or months after the surgery could be regarded as favourable, but low level of HDL is an independent risk factor for heart diseases. Extreme load on the liver without preparation of the patient to the surgery can have negative consequences.

Methods

The test group comprised of 40 female patients at the age of 42.96 with average body weight of 131.56 kg and BMI 46.49. Biochemical analyses were performed using calorimetric method.

Results

No statistically significant differences were observed in glucose levels between the two types of procedures. The highest differences were noted for triglycerides levels, which decreased, as well as all cholesterol fractions, after RYGB, but were increasing during the first months after SG procedure. Changes in lipid profile, caused by the reduction of all lipid fractions, were more visible after RYGB. The decrease in total cholesterol directly and activity of liver enzymes after the procedure was as higher after RYGB as after SG. Increased activity of transaminases indicates significant liver overload.

Conclusions

With the selection of groups of patients with similar initial parameters, it is not clear whether the differences between the two procedures when assessing the improvement of glycaemia are significant. However, due to invasive character of RYGB, liver overload lasting several months and lifelong limited absorption of nutrients, the possibility of SG procedure should be considered as a first option.

Metabolic risk factors of coronary heart disease in relation to anthropometric measures in nonalcoholic fatty liver disease patients following dietary intervention

Wstęp:Niealkoholowa stłuszczeniowa choroba wątroby (NAFLD) jest związana z wysokim ryzykiem zaburzeń metabolicznych (zespół metaboliczny, cukrzyca typu 2) oraz choroby wieńcowej.Materiały i metody: Grupę badaną stanowiło 108 osób dorosłych rasy kaukaskiej (39 kobiet i 69 mężczyzn) w wieku 20–77 lat z rozpoznaną NAFLD. Podstawą diagnozy było dokładne badanie USG wątroby oraz analiza parametrów wątrobowych: aminotransferazy alaninowej i aminotransferazy asparaginianowej w surowicy. Wszystkie badania przeprowadzono podczas pierwszej i ostatniej wizyty pacjentów w placówce badawczej (po 6 miesiącach od interwencji dietetycznej). Dokonywano także pomiarów antropometrycznych (wskaźnik masy ciała – BMI, obwód pasa – WC, wskaźnik talia–biodra – WHR, wskaź- nik talia–wzrost – WHtR, wskaźnik stożkowatości – C -Index) w odniesieniu do metabolicznych czynników ryzyka choroby niedokrwiennej serca (podwyższone stężenie w surowicy: triacylogliceroli, cholesterolu lipoprotein niskiej gęstości, cholesterolu całkowitego, glukozy oraz obniżone stężenie cholesterolu lipoprotein wysokiej gęstości).Wyniki: Zarówno w grupie kobiet, jak i mężczyzn wykazano istotną statystycznie redukcję wartości parametrów takich jak: masa ciała, BMI, WC, WHR, WHtR i C -Index (p < 0,05), co miało wpływ na poprawę stężenia triacylogliceroli w surowicy u obu płci (p < 0,05). Wskaźniki identyϐikujące otyłość brzuszną (WC, WHR, WHtR, C -Index) korelowały istotnie z wartością glikemii (p < 0,05) zarówno przed interwencją dietetyczną, jak i po niej oraz ze stężeniem lipidów w surowicy przed interwencją lub po (p < 0,05) u obu płci.Wnioski: Rozpowszechnienie użycia prostych narzędzi antropometrycznych (przede wszystkim C -Index i WHtR) wydaje się być korzystne, zwłaszcza na szczeblu podstawowej opieki zdrowotnej. Narzędzia te mogą służyć zarówno do prewencji, jak i wczesnego wykrywania metabolicznych czynników ryzyka choroby niedokrwiennej serca, a co za tym idzie potencjalnie śmiertelnych konsekwencji incydentów wieńcowych u pacjentów z NAFLD lub z innymi zaburzeniami metabolizmu.

Elaidic acid and vaccenic acid in the plasma of pregnant women and umbilical blood plasma

INTRODUCTION

The studies suggest that trans fatty acids are the most harmful type of fatty acids, and their ingestion leads to an increase in oxidative stress, changes in the plasma levels of LDL cholesterol, and a reduction in n-6 and n-3 fatty acids utilization. The objective of this study was to determine the concentration profiles of elaidic and vaccenic acids in maternal blood plasma in the perinatal period, and in the plasma of blood collected from the umbilical vein. The article deals with the issue of the correlation between the levels of trans-unsaturated fatty acids in maternal and neonatal blood, which could suggest the transplacental transport of these acids. The potential correlations between the levels of trans-unsaturated fatty acids in maternal and umbilical blood and birth weight and body length in neonates was also verified.

MATERIAL AND METHODS

The study group comprised 53 pregnant patients of the Clinic of Obstetrics and Perinatology of the Pomeranian Medical University in Szczecin, aged 18-39 years, together with their newborn babies. Elaidic and vaccenic acid levels were determined in maternal and umbilical plasma. Fatty acid methyl esters were injected onto the capillary column of the Agilent 6890M gas chromatography system integrated with an autosampler. The content of individual fatty acids was determined from the reference curves and expressed in mg/mL.

RESULTS

The lowest levels of both acids were observed in umbilical blood plasma. The level of elaidic acid was 0.0019 mg/mL ± 0.0013 mg/mL, while the level of vaccenic acid was 0.0007 mg/mL ± 0.0011 mg/mL. A statistically significant negative correlation was observed between maternal vaccenic acid levels and umbilical vaccenic acid levels.

CONCLUSIONS

The presence of trans-unsaturated fatty acids (elaidic acid and vaccenic acid) in umbilical plasma is evidence of the transplacental transport of these acids. The significantly higher levels of elaidic acid compared to vaccenic acid in umbilical plasma suggests that vaccenic acid is more extensively metabolized in placenta. The levels of trans-unsaturated fatty acids had no effect on birth weight and body length in neonates.

Metabolites of arachidonic acid and linoleic acid in early stages of non-alcoholic fatty liver disease--A pilot study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a spectrum of liver conditions related to fat infiltration. The role of liver triacylglycerol accumulation in NAFLD is not fully understood.

METHODS

Twenty-four patients, 12 in the first and 12 in the second stage of NAFLD, were prospectively enrolled in this study. Biochemical parameters and eicosanoids (HETE and HODE) were compared between the first and the second stage of hepatic steatosis and the effect of a 6-month dietary intervention on these parameters was evaluated. Eicosanoid profiles were extracted from 0.5 ml of plasma using solid-phase extraction RP-18 SPE columns. The HPLC separations were performed on a 1260 liquid chromatograph.

RESULTS

Patients with stage I NAFLD had a significantly higher level of HDL cholesterol and a lower level of 5-HETE. Patients with grade II steatosis had higher concentrations of 9-HODE. Following the six-month dietary intervention, hepatic steatosis resolved completely in all patients. This resulted in a significant decrease in the concentrations of all eicosanoids (LX4, 16-HETE, 13-HODE, 9-HODE, 15-HETE, 12-HETE, 5-oxoETE, 5-HETE) and key biochemical parameters (BMI, insulin, HOMA-IR, liver enzymes).

CONCLUSION

A significant reduction in the analyzed eicosanoids and a parallel reduction in fatty liver confirmed the usefulness of HETE and HODE in the assessment of NAFLD.

Fatty acid changes help to better understand regression of nonalcoholic fatty liver disease

AIM: To investigate whether liver steatosis reduction due to a six-month dietary intervention results in significant changes in the concentrations of fatty acids.

METHODS: A group of 35 Caucasian individuals diagnosed with different levels of steatosis were prospectively enrolled in the present study. Analysis of the fatty acid profiles was performed according to changes in liver steatosis (liver steatosis reduction by one or two degrees) after a six-month dietary intervention. The diet helped reduce body mass in obese and overweight patients, and stabilize both glycemia and dyslipidemia. Fatty acids were extracted according to the Folch method and analyzed by gas chromatography.

RESULTS: This study showed significant changes in fatty acid profiles in patients who had reduced liver steatosis by one as well as two degrees. A reduction in liver steatosis by one degree caused a significant increase in the level of the n-3 family: eicosapentaenoic acid (P < 0.055), docosapentaenoic acid-C 22:5 (P < 0.05) and docosahexaenoic acid (P < 0.05). A reduction in liver steatosis by two degrees caused a significant decrease in serum palmitoleic acid-C 16:1 (P < 0.05).

CONCLUSION: Liver steatosis reduction is associated with changes in fatty acid profiles, and these changes may reflect an alteration in fatty acid synthesis and metabolism. These findings may help better understand regression of nonalcoholic fatty liver disease.

[Trans fatty acids (elaidic and vaccenic) in the human milk]

INTRODUCTION

The structure of trans unsaturated fatty acids (TFAs) includes at least one double bond with a trans configuration. Numerous studies have shown that TFAs influence negative changes in blood lipid profile, may initiate or accelerate the course of many inflammatory diseases, and reduce n-6 and n-3 fatty acids' utilization. Their presence in tissues and systemic fluids is mainly the result of ingestion of TFA-containing foods. The objective of this study was to determine the concentration profiles of elaidic and vaccenic acids in human milk, and the existence of potential correlations between the levels of trans-unsaturated fatty acids and long chain polyunsaturated fatty acids.

MATERIALS AND METHODS

The study group consisted of 53 lactating women, aged 18-39 years, 5-6 weeks after delivery. Elaidic and vaccenic acid levels were determined in human milk. Fatty acid methyl esters were injected onto the capillary column of an Agilent 6890M gas chromatography system integrated with an autosampler. Geometrical and positional isomers of fatty acids were identified by comparing their retention times with those of the fatty acid standards from Sigma-Aldrich. The content of individual fatty acids was determined from the reference curves and expressed in mg/mL.

RESULTS

The level of elaidic acid was 0.2572 ± 0.1811 mg/mL, and the level of vaccenic acid was 0.2736 ± 0.1852 mg/mL. No negative correlations between the levels of the analyzed TFAs and PUFAs were observed in human milk.

CONCLUSIONS

The levels of elaidic and vaccenic acid were similar and had no negative influence on the levels of arachidonic acid and docosahexaenoic acid.

[Effects of dietary trans fatty acids in pregnancy and lactation]

Unsaturated fatty acids with the trans configuration (TFA) are recognized as the most harmful type of fatty acids. The main human source of TFA are foods containing hardened plant oils. Evidence is aplenty that TFA are responsible for increased risk of cardiovascular diseases, tumors, type 2 diabetes, and inflammatory conditions. Due to the harmful action of TFA it is of particular importance to determine the exact effects of TFA on pregnancy and fetal development which will in consequence affect the health of adults. It is believed that the inhibited synthesis of polyunsaturated fatty acids in the presence of TFA is among factors that determine birthweight, duration of pregnancy, and development of the nervous system during intrauterine life and after birth. Pregnant women consuming significant amounts of TFA are at risk of pregnancy-induced hypertension, preeclampsia, and insulin resistance. Reports on the harmful action of TFA on humans persuasively reveal the need to limit their intake, particularly during pregnancy and lactation.