Resting energy expenditure and nutritional state in patients with liver cirrhosis before and after liver transplantation

Resting energy expenditure (REE), body composition, and the biochemical parameters of liver function were measured in 26 patients before and 432 days (range: 103-1022 days) after liver transplantation (LTX). PreLTX REE was variable (mean: 1638 +/- 308 kcal/day, range: 1220-2190 kcal/day or +10 +/- 11% of Harris Benedict = HB prediction, range: -19 - +33%) and was closely related to body cell mass (r = 0.66, p < 0.0003). PostLTX REE was variable (mean: 1612 +/- 358 kcal/day, range: 1010-2490 kcal/day or +5 +/- 15% of HB prediction, range: -20 - +37%) and was closely related to body cell mass (r = 0.65, p < 0.0006). When compared with preLTX values only small changes in mean REE (-71 +/- 43 kcal/day) and a close correlation between pre and postLTX REE (r = 0.82, p < 0.001) were observed. In contrast to REE, changes in body weight were highly variable (-16.5 - +32.7 kg/year). This variance was not explained by the number of postoperative complications, pre and postLTX liver function, possible graft rejection and/or hepatitis reinfection. Pre-operative hypermetabolism (i.e. REE >+20% of HB prediction) was associated with postoperative hypermetabolism and a reduced liver function before and after LTX. Hypermetabolic patients had a poorer nutritional outcome after LTX (weight change: 0 +/- 8.4 kg/year) when compared with normometabolic controls (weight change: +5.7 +/- 7.4 kg/year; p < 0.05). There was no significant association between deviations in pre and postLTX REE and changes in body weight. When corrected for changes in the nutritional state our data provide evidence for the persistence of resting energy expenditure in liver transplant patients.     

Increased energy expenditure after intravenous administration of amino acids.

Nutrient-induced thermogenesis (NIT) after parenteral administration of amino acids (AAs) was investigated in rats and compared with result obtained with intragastric administration. Resting energy expenditure was measured with a new type of open-circuit indirect calorimeter. The NIT increased shortly after parenteral AAs administration and reached a steady state in 30 minutes. The change in resting energy expenditure (the increment of resting energy expenditure over preinfusion baseline values) showed a significant relationship not only with the amount of infused AAs but also with the AA concentration in the portal vein. Furthermore, the increase in plasma AA concentrations in the portal vein was proportional to the amount of the particular AA infused. This relationship held true over the entire range tested. NIT with parenteral infusion (11% to 12%) was lower than that with intragastric infusion (20% to 23%). Plasma insulin, corticosterone, and glucagon levels increased after both parenteral and intragastric AAs administration, but the two methods did not show any significant differences in hormonal changes. The plasma aminogram of the portal vein after intragastric infusion was compared with that after parenteral infusion. Total plasma AA concentration and the levels of glutamine, lysine, arginine, glutamate, aspartate, and histidine were lower but the level of isoleucine was higher after intragastric infusion. On the basis of these results, it is believed that parenteral administration of AAs can induce thermogenesis, which may be regulated by the intraportal AA concentration. Considering the remarkable decrease in glutamine in the portal vein after intragastric infusion, the cost of intestinal metabolism may predominantly contribute to the NIT resulting from intragastric infusion.     

Resting energy expenditure in cancer patients before and after gastrointestinal surgery.

The aim of this study was to assess the impact of surgical trauma on energy metabolism in cancer patients. Therefore, resting energy expenditure (REE) was determined before and after surgery in patients with newly detection gastric and colorectal cancer. Preoperative REE was measured in 104 patients. In 65 of these 104 patients REE was also measured on the seventh or eighth postoperative day. Postoperative REE was significantly higher than preoperative REE (mean +/- SD: 1471 +/- 238 vs 1376 +/- 231 kcal; p less than 0.001). After surgery 22 patients were hypermetabolic (REE greater than or equal to 115% predicted energy expenditure) compared with seven hypermetabolic patients before surgery. This hypermetabolism in the postoperative state can be explained by the administration of total parenteral nutrition (TPN), by an increased body temperature mainly as a consequence of postoperative complications and by the surgical trauma itself. Patients who received preoperative TPN (n = 12) showed a 10% increase in REE. Thirteen patients suffered from minor and major postoperative complications; postoperative REE in this group was increased by 10%. Forty patients who had undergone uncomplicated surgery showed a slight but significant increase of 3% in REE after operation. We conclude from this study that the increase in REE resulting from surgical trauma itself is modest at the seventh to eighth postoperative day. Therefore, energy requirements for patients undergoing major elective surgical stress are lower than generally presumed.     

Overfeeding and energy expenditure in humans.

The effect of overfeeding on energy expenditure was investigated in 23 young men subjected to a 353-MJ energy intake surplus over 100 d. The major part of this excess (222 MJ) was stored as body energy. The increase in energy cost of weight maintenance amounted to 52 MJ and was proportional to body weight gain. When it was added to the obligatory cost of fat and fat-free mass gains, the overall increase in energy expenditure amounted to a mean of 100 MJ. Four months after overfeeding, subjects had lost 82%, 74%, and 100% of the overfeeding gain in body weight, fat mass, and fat-free mass, respectively. We conclude that 1) in response to overfeeding, two-thirds of the excess energy intake is stored as body energy; 2) overfeeding induces an increase in energy cost of weight maintenance proportional to body weight gain, and 3) preoverfeeding energy balance tends to be restored when nonobese individuals return to their normal daily-life habits.     

Resting energy expenditure in cancer patients.

In this review, we provide evidence based on our studies, for zinc deficiency and cell mediated immune disorders, and the effects of protein and zinc status on clinical morbidities in patients with head and neck cancer. We investigated subjects with newly diagnosed squamous cell carcinoma of the oral cavity, oropharynx, larynx, and hypopharynx. Patients with metastatic disease and with severe co-morbidity were excluded. Nutritional assessment included dietary history, body composition, and prognostic nutritional index (PNI) determination. Zinc status was determined by zinc assay in plasma, lymphocytes, and granulocytes. Pretreatment zinc status and nutritional status were correlated with clinical outcomes in 47 patients. Assessment of immune functions included production of TH1 and TH2 cytokines, T cell subpopulations and cutaneous delayed hypersensitivity reaction to common antigens.

At baseline approximately 50% of our subjects were zinc-deficient based on cellular zinc criteria and had decreased production of TH1 cytokines but not TH2 cytokines, decreased NK cell lytic activity and decreased proportion of CD4+ CD45RA+ cells in the peripheral blood. The tumor size and overall stage of the disease correlated with baseline zinc status but not with PNI, alcohol intake, or smoking. Zinc deficiency was associated with increased unplanned hospitalizations. The disease-free interval was highest for the group which had both zinc sufficient and nutrition sufficient status.

Zinc deficiency and cell mediated immune dysfunctions were frequently present in patients with head and neck cancer when seen initially. Zinc deficiency resulted in an imbalance of TH1 and TH2 functions. Zinc deficiency was associated with increased tumor size, overall stage of the cancer and increased unplanned hospitalizations. These observations have broad implications in the management of patients with head and neck cancer.     

The measurement of energy expenditure.

Proper nutrition support depends upon the clinician's ability to estimate the patient's energy expenditure. The accuracy of estimation is inversely proportional to the severity of the patient's illness. This fact has spurred academic and industry groups to pursue the measurement of energy expenditure. Harris and Benedict used indirect calorimetry to develop their now-famous equation nearly 100 years ago. The concept of indirect calorimetry is simple; if you know the concentration of inspired gases and expired gases, along with the flow, you can determine the amount of a gas consumed or produced. The complexity and expense of indirect calorimeters suggest that this simple concept is technically challenging. Because we desire to know the energy expenditure of the most critically ill patients, indirect calorimetry is further confounded by the presence of oxygen and mechanical ventilation. This paper will discuss the myriad of variables and obstacles that complicate the measurement of energy expenditure and will suggest methods to avoid or overcome them.     

Changes in resting energy expenditure among children undergoing allogeneic stem cell transplantation

BACKGROUND: Because of the effects of chemotherapy and radiotherapy, patients undergoing stem cell transplantation (SCT) are commonly provided nutritional support with parenteral nutrition. The energy and nutrient needs of these patients have not been well studied. OBJECTIVE: The objective was to measure resting energy expenditure (REE), dietary intake, and biochemical and anthropometric changes in children before and after allogeneic SCT. DESIGN: This was a prospective cohort study of 37 children aged 9.1 +/- 6.4 y ( +/- SD) undergoing SCT who were enrolled in an open-label trial of a unique supportive care intervention that included the routine use of oral leucovorin, vitamin E, and ursodeoxycholic acid. Parenteral nutrition was provided to match 100% of measured or estimated REE. REE was measured weekly via indirect calorimetry. RESULTS: Baseline REE was 95% of the predicted age- and sex-matched norms and was significantly correlated with midarm muscle area (r = 0.82, P < 0.001). REE fell to a nadir of approximately 80% of the predicted levels by week 3 after SCT, with a gradual increase in weeks 4 and 5. Arm anthropometric measurements showed no change in triceps skinfold thickness but significant declines in midarm muscle area after SCT. Serum vitamin E remained in the normal range. CONCLUSIONS: Children undergoing SCT show significant declines in REE after transplantation. These changes may be due to alterations in lean body mass. Standard nutritional regimens may lead to overfeeding.     

Lean-body-mass composition and resting energy expenditure before and after long-term overfeeding.

This report deals with the association between the constituents of lean body mass (LBM) and resting metabolic rate (RMR) before and after a 100-d overfeeding period. Computed-tomography (CT) scan of 22 young adult males at nine different body levels were used to estimate adipose tissue mass (ATMCT), LBMCT, skeletal-muscle mass (SMMCT), and non-muscular LBMCT (NM-LBMCT). Before overfeeding, all body constituents, except ATMCT, were significantly correlated with RMR. Only body mass changes were significantly correlated with RMR changes. Comparison of these results with those of several studies in the literature reveals that the relationship between RMR and fat-free mass is highly influenced by the size of the SD for the latter variable. In stepwise-multiple-regression analysis, only SMMCT could be used to predict RMR. It was concluded that SMMCT and ATMCT, but not NM-LBMCT, increased during overfeeding and that the best correlates of RMR remain LBMCT, SMMCT, and body mass.     

Twenty-four-hour analysis of elevated energy expenditure after physical activity in a metabolic chamber: models of daily total energy expenditure

BACKGROUND: The Institute of Medicine proposed that 15% of energy expenditure (EE) as excess post-exercise oxygen consumption should be added to additional physical activity energy expenditure (DeltaPAEE) to estimate total EE. However, the magnitude of elevated post-physical activity energy expenditure (EPEE) under normal daily living conditions has not been examined. OBJECTIVE: We examined the effects of EPEE on 24-h EE by modeling standard living conditions in a metabolic chamber. DESIGN: Eleven Japanese men completed three 24-h metabolic chamber measurements: a control day (C-day), a day with high-frequency moderate-intensity physical activity (M-day), and a day with high-frequency vigorous-intensity physical activity (V-day). RESULTS: Mean (+/- SD) 24-h EE for the C-day, the M-day, and the V-day was 2228 +/- 143 kcal, 2816 +/- 197 kcal, and 2813 +/- 163 kcal, respectively. No significant difference was observed in 24-h EE between an M-day and a V-day. Mean EPEEs on the M-day and the V-day did not significantly contribute to increasing 24-h EE. Relative EPEEs to DeltaPAEEs were 6.2 +/- 13.9% (M-day) and 5.1 +/- 9.2% (V-day). However, EPEE/24-h EE was negatively correlated with maximal oxygen uptake on the V-day (r = -0.68, P = 0.02), although no significant correlation between these variables was observed on the M-day (r = -0.41, P = 0.21). CONCLUSIONS: These results suggest that EPEE has a small effect on 24-h EE in the course of normal daily activities, findings that do not support the proposition by the Institute of Medicine for estimating TEE. However, persons with low physical fitness levels could enhance EE as EPEE by increasing vigorous-intensity daily physical activity.     

Resting energy expenditure in diabetic and nondiabetic patients with liver cirrhosis: relation with insulin sensitivity and effect of liver transplantation and immunosuppressive therapy

BACKGROUND: Hypermetabolism, insulin resistance, and diabetes are common in patients with liver cirrhosis. OBJECTIVE: We assessed whether diabetes and insulin resistance influence postabsorptive energy homeostasis in these patients and whether liver transplantation (LTx) and immunosuppressive drugs affect these relations. DESIGN: Twenty-six patients with liver cirrhosis (16 with and 10 without diabetes) were studied with an insulin clamp and indirect calorimetry. Eleven of these subjects were studied 9 mo after LTx to longitudinally assess its effects. To cross-sectionally explore a longer follow-up period, we studied 65 patients 6, 14, and 32 mo after LTx. Seven patients with chronic uveitis (receiving immunosuppressive therapy) and 20 healthy subjects served as control subjects. RESULTS: Diabetic and nondiabetic patients with cirrhosis had insulin resistance (S(I(clamp)); P < 0.03) and higher measured resting energy expenditure (REE) as a percentage of predicted REE than did healthy subjects (107.6 +/- 1.8% compared with 97.4 +/- 2.3%; P < 0.03), and these 2 alterations were associated (R(2) = 0.119, P = 0.0002). The longitudinal study showed an improvement in the 2 variables after LTx, but full restoration was not achieved. The cross-sectional analysis confirmed this observation in patients studied 6 mo (n = 28) after LTx. In patients studied 14 (n = 21) and 32 mo (n = 16) after LTx, S(I(clamp)) and measured REE as a percentage of predicted REE were not significantly different from those in control subjects. CONCLUSIONS: In patients with liver cirrhosis, higher-than-normal postabsorptive REE was associated with insulin resistance regardless of diabetes. This abnormality persisted in patients studied 6-9 mo after LTx but improved simultaneously with the improvement in insulin sensitivity thereafter.     

Resting energy expenditure, activity energy expenditure and total energy expenditure at age 91-96 years

There is a limited knowledge concerning energy requirements of the elderly, especially the oldest old (> 80 years). Energy requirements should be estimated from measurements of energy expenditure. For this purpose twenty-one free-living individuals (eight males, thirteen females) aged 91-96 years living in G?teborg, Sweden were studied. Total body water (TBW) measured by the doubly-labelled-water (DLW) technique was 29.5 (sd 5.4) kg in females and 35.6 (sd 4.3) kg in males. TBW measured using bioelectric impedance (BIA) was 31.6 (sd 6.4) kg in females and 42.0 (sd 7.4) kg in males. The mean difference between TBW measured by BIA and that measured by DLW was 3.54 (sd 3.6) kg (P = 0.0002). Resting metabolic rate (RMR) was measured using a ventilated-hood system and averaged 5.36 (sd 0.71) MJ/d in females (n 12) and 6.09 (sd 0.91) MJ/d in males (n 8). Difference between measured RMR and predicted BMR (n 20) was 0.015 (sd 0.86) MJ/d (NS). Total energy expenditure (TEE) measured by DLW averaged 6.3 (sd 0.81) MJ/d in females and 8.1 (sd 0.73) MJ/d in males. Activity energy expenditure (TEE - RMR), thus including diet-induced thermogenesis (DIT), averaged 0.95 (sd 0.95) MJ/d in females (n 12) and 2.02 (sd 1.13) MJ/d in males. Physical activity level (TEE/BMR) averaged 1.19 (sd 0. 19) in females and 1.36 (sd 0.21) (P = 0.08) in males. If DIT is assumed to be 10 % of the TEE, energy spent on physical activity will be very low in this population.     

Machiguenga energy expenditure

This article presents the results of a study of energy expended at typical activities and on average days, by adult women and men of a hunter‐gatherer‐horticulturalist population in south‐eastern Peru. Marked differences between the sexes in patterns of energy use are presented. The men tended to work at higher rates of energy expenditure than did the women. On the average day, representative of all activities in an annual cycle, the women expended only about 8.0 MJ (1925 Cals) whereas the men expended about 13.3 (3200 Cals). Seasonal analysis reveals an even greater contrast during the wet months. Relations between the Machiguenga and their upper Amazonian rain forest environment are considered in accounting for the observed patterns of energy expenditure. Factors such as differences in uses of technology, work settings, and population composition are related to the findings.     

Resting energy expenditure in patients with end-stage liver disease and in normal population

Resting energy expenditure (REE) was measured in 10 patients with end-stage liver disease (ELD) and in 31 normal controls. Basal energy expenditure (BEE) was also predicted by the Harris-Benedict equation. In order to correlate REE to lean body mass, the 24-hr urinary creatinine was measured in patients with ELD and in normal controls and expressed as kcal/g urinary creatinine. Linear regression analysis showed a statistically significant (p less than 0.0001) correlation (r = 0.72) between the REE and the 24-hr urinary creatinine in normal controls, irrespective of age and sex. Mean BEE (1580 +/- 160 vs 1575 +/- 210) and REE (1755 +/- 215 vs 1800 +/- 330) were not significantly different between patients with ELD and controls. However, the mean REE was 1900 +/- 610 kcal/g creatinine in patients with ELD and 1180 +/- 260 (p less than 0.0001) in controls. When related to lean tissue, patients with ELD had increased energy expenditure, confirming the hypermetabolic state suggested on clinical grounds. The use of urine creatinine to estimate energy expenditure may be a simple clinical technique to predict dietary energy needs in malnourished, unstressed patients. When this estimated energy expenditure/g creatinine (EEE) is compared to measured energy expenditure/g creatinine in malnourished, stressed patients, the EEE provides an index of the extent of hypermetabolism.     

Early postprandial energy expenditure and macronutrient use after a mixed meal in cirrhotic patients.

The effect of meal ingestion (9 kcal/kg of body weight, 53% carbohydrate, 30% fat, 17% protein, as a liquid formula) on energy expenditure and oxidation rate of carbohydrate, fat, and protein was assessed by indirect calorimetry and urinary nitrogen excretion before and for 3 hours after eating in stable cirrhotic patients and control subjects of comparable age. Postprandial modifications of substrate and hormone levels were also studied. Compared with basal values, the mean +/- SD resting energy expenditure during the first 3 hours after meal ingestion increased similarly in cirrhotic patients (+0.32 +/- 0.12 kcal/min) and control subjects (+0.31 +/- 0.08 kcal/min). Dietary induced thermogenesis was equivalent to 10% of the energy contained in the meal in both groups. Before eating, the carbohydrate oxidation rate was lower and fat oxidation higher in cirrhotic patients than in the control subjects. After eating, glucose oxidation increased whereas fat and protein oxidation rates were reduced in both groups. As a consequence the amount of fat oxidized in the postprandial period remained higher in cirrhotic patients than in the control subjects. After meal ingestion, serum glucose levels increased whereas plasma free fatty acid and glycerol levels decreased in both groups. The substrates, however, remained significantly higher in cirrhotic patients than in control subjects, despite the higher postprandial insulin increment in the patients group, thus suggesting the presence of insulin resistance. Because the postprandial glucose oxidation rate was normal, the low insulin-mediated glucose uptake observed in cirrhotic patients seems to reflect a defect in the nonoxidative disposal of the glucose ingested.(ABSTRACT TRUNCATED AT 250 WORDS)     

Increased energy expenditure after dilutional exchange transfusion for neonatal polycythemia

OBJECTIVE: Hypothermia is a known symptom of neonatal polycythemia (NP) and its pathophysiology is unclear. The effect of partial dilutional exchange transfusion (PET) upon resting energy expenditure (REE) is unknown. We aimed to test the hypothesis that PET leads to an increase in REE. STUDY DESIGN: 11 patients with NP who underwent PET and 10 controls without polycythemia were studied. NP was defined as a venous HCT >/=0.65. Per protocol, symptomatic infants and/or those with venous HCT > or =0.70 underwent PET. REE was measured just prior and 23 hours after PET in patients with NP and at identical ages in the control group. Infants were studied in a skin servo controlled radiant warmer, while clinically and thermally stable, prone and asleep. Measurements were stopped during body movements (less than 5% of the time of measurement). Metabolic measurements were performed by indirect calorimetry, using the Deltatrac II Metabolic monitor (Datex-Ohmeda, Helsinki, Finland). This instrument uses the principle of the open circuit system that allows continuous measurements of oxygen consumption (Vo(2)) and carbon dioxide production (Vco(2)) using a constant flow generator. REE measurements were corrected for the infant weight (Kcal/kg/d). Comparison of REE values between groups was performed using paired Wilcoxon ranked test. RESULTS: Patients with and without NP had nearly identical baseline REE. In patients with NP, REE increased from 44.0 +/- 6.6 Kcal/Kg/d to 48.3 +/- 5.1 Kcal/Kg/d after PET (P<0.05). Furthermore, the increase in REE following PET correlated inversely with the decrease in hematocrit. There was no significant change in REE over time in the control group. In the NP group, symptomatic infants (n=5) had a significantly greater increase in REE following PET than non-symptomatic ones (1.4 +/- 6.3 vs. 7.8 +/- 4.9 Kcal/Kg/d, p<0.05). CONCLUSIONS: Energy expenditure of polycythemic infants increases following PET, in a manner proportional to the decrease in hematocrit. Symptomatic polycythemic infants have a greater rise in REE following PET than non-symptomatic ones. We speculate that polycythemia leads to a decreased REE that might be remedied by PET.     

Relationship of resting energy expenditure with liver function and nutritional status in patients with alcoholic cirrhosis.

Resting energy expenditures (REEs) were measured in 40 alcoholic cirrhotic (AC) patients by indirect calorimetry and corrected for 24-h urinary creatinine and excretion. These REEs were compared according to the stage of severity of the cirrhosis, the nutritional status, and the presence or absence of alcoholic hepatitis (AH). Mean REE was not significantly different between the Child class A, B, and C patients, even when corrected for 24-h urinary creatinine. Mean REE was significantly less in malnourished AC than in well-nourished patients (1308 +/- 285 vs. 1531 +/- 255 kcal, p less than 0.02). However, when measured energy expenditure was corrected for 24-h urinary creatinine, the difference between the two groups of patients disappeared (1800 +/- 540 kcal/g creatinine in malnourished patients vs. 1890 +/- 780 kcal/g creatinine in well-nourished patients). Finally, there was no significant difference between the REE, corrected or not, for the 24-h urinary creatinine in AC with or without AH. Thus, when REE is normalized to lean body mass, represented by 24-h urinary creatinine, the metabolic activity in AC is not dependent on the severity of the cirrhosis, nutritional status, or existence of AH.