Nutritional support in alcoholic liver disease: a review

Nutritional therapy plays a major role in the management of patients with Alcoholic Liver Disease (ALD). This paper attempts to review current clinical practice in this field and includes classification of alcoholic liver disease, causes of nutritional deficiency, assessment of nutritional status and the recommended dietary management.     

慢性肝病的营养支持

营养不良在肝病患者中很常见,其严重程度直接关系到患者的短期生存率,营养支持作为治疗慢性肝病的重要手段,对于慢性肝病患者的长期治疗与恢复非常必要.评价慢性肝病患者营养状态有多种方法,包括直接人体测量法、生化指标检测、免疫学指标、营养评定工具、人体组成测定等,各有优缺点,可从不同侧面综合评价营养状况.在进行营养支持时,应结合肝病的具体情况与患者的耐受能力,选择合适的营养物质与营养途径.     

慢性肝病的营养支持

营养不良在肝病患者中很常见,其严重程度直接关系到患者的短期生存率,营养支持作为治疗慢性肝病的重要手段,对于慢性肝病患者的长期治疗与恢复非常必要。评价慢性肝病患者营养状态有多种方法,包括直接人体测量法、生化指标检测、免疫学指标、营养评定工具、人体组成测定等,各有优缺点,可从不同侧面综合评价营养状况。在进行营养支持时,应结合肝病的具体情况与患者的耐受能力,选择合适的营养物质与营养途径。     

Nutritional support in alcoholic cirrhotic patients improves host defenses.

BACKGROUND: Malnutrition is usual in patients with alcoholic liver disease and is associated with a poor outcome. Nutritional support decreases nutrition-associated complications. AIM: To demonstrate that nutritional support in ambulatory alcoholic cirrhotic patients improves host defenses. METHODS: Thirty-one male outpatients with alcoholic cirrhosis CHILD-PUGH B or C were included. Twenty-five subjects completed six months consuming daily a nutritional supplement (Ensure, 1000 Kcal and 35 g protein), in addition to their regular diet. At entrance and every three months, a clinical assessment, nutritional evaluation and indirect calorimetry were performed. Liver function tests and LPS-induced monocyte production of cytokines, salivary secretory IgA, lactulose/mannitol ratio and breath hydrogen tests were also measured in these intervals. Delayed cutaneous hypersensitivity and IgG and IgM antibody response to endotoxin were assessed at entrance and at the end of the study. RESULTS: Patients drank 85% of the provided supplement as an average. REE, total body fat and serum albumin increased, basal breath hydrogen decreased and cellular immunity improved significantly during the follow up period (p< or =0.03). All the other parameters remained unchanged throughout the study. Six patients (16.2%) died during the study, five due to upper gastrointestinal bleeding. CONCLUSION: Nutritional support in alcoholic cirrhotic patients improves nutritional status and cell mediated immunity.     

住院患者营养风险筛查及营养支持状况

目的分析中山大学附属第一医院住院患者的营养风险、营养不足发生率以及临床营养支持的应用状况。方法采用定点连续抽样方法,对2005年8-12月在第一医院消化内科、肾内科、呼吸内科、普通外科、胸外科868例住院患者进行营养筛查,并调查其营养支持应用情况,分析营养风险和营养支持之间的关系。结果868例患者中,发生营养不足和营养风险分别为183,329例,分别占21.1%,37.9%;5个专科中,181例消化内科患者的营养不足和营养风险发生率均最高,分别为52,96例,分别占28.7%,53.0%;全部患者中,212例进行营养支持,占24.4%;其中329例有营养风险患者中,122例进行营养支持,占37.1%;539例无营养风险患者中。90例行营养支持,占16.7%。结论住院患者中存在较高比例的营养风险或营养不足;肠外肠内营养临床应用存在不合理性。     

Nutritional status of alcoholic patients: it's possible relationship to alcoholic liver damage

This study was performed to look for a possible relationship between the nutritional status and the presence of liver damage in alcoholic patients. One hundred chronic alcoholics admitted for treatment to the Alcoholism Ward, without clinical signs of liver failure, were studied. In 84, anthropometric nutritional indexes, liver function tests, and a liver biopsy were performed; in 69 patients a dietary survey was obtained. A dietary imbalance was observed in the total group; 65% of ingested calories were derived from ethanol. The intake of proteins, vitamins, and minerals was below the RDA, NAS/USA, and no differences were found between patients with and without liver damage. Neither were significant differences in daily alcohol calories or total ethanol dose found between both groups of patients. Mean anthropometric values were within 80 to 100% of commonly used standards. However, patients with alcoholic hepatitis and/or cirrhosis had a significantly higher percentage of ideal body weight, compared to alcoholics with normal livers or less severe histological alterations (109.7 +/- 20.3 versus 95.6 +/- 12.5, SD, p less than 0.005). A similar difference was observed in arm muscle areas. These findings show that overweight is associated with liver alterations in the alcoholic and should be investigated as a risk factor to develop liver damage.     

Nutritional and metabolic effects of alcoholism: their relationship with alcoholic liver disease.

Excessive alcohol ingestion disturbs the metabolism of most nutrients. Although alcohol can lead to severe hypoglycemia, alcoholics are usually glucose intolerant, probably due to a inhibition of glucose-stimulated insulin secretion. Ethanol intake also leads to negative nitrogen balance and an increased protein turnover. Alcohol also alters lipid metabolism, causing a profound inhibition of lipolysis. Looking for an association between alcohol intake, nutrition, and alcoholic liver disease, we have observed a higher prevalence of subclinical histologic liver damage among obese alcoholics. Multivariate analysis in a large group of alcoholics has shown that obesity is an independent predictor of alcoholic liver disease. Other authors have reported that alcoholics with a history of obesity have a two to three times higher risk of having alcoholic liver disease than non-obese alcoholics. The possible explanation for this association is that the microsomal system, which plays an important pathogenic role in alcoholic liver disease, is induced in non-alcoholic obese subjects and alcoholics. Also, peripheral blood monocyte cells of obese alcoholics produce higher levels of interleukin-1, a cytokine that can contribute to liver damage. The ingestion of polyunsaturated fatty acids can also increase the damaging effects of alcohol on the liver, as has been demonstrated in rats subjected to continuous intragastric infusion of alcohol. Observations in human alcoholics have shown that liver damage is associated with a higher ratio of C:18:1/C:18:0 and a lower ratio of C:22:4/C:18:2 in liver lipids, consistent with an induction of delta 9 desaturase and an increased peroxidation of C:22:4.     

Enteral and parenteral branched chain amino acid-supplemented nutritional support in patients with encephalopathy due to alcoholic liver disease

The effects of branched chain amino acid (BCAA)-enriched diets (fed for 7 days) on encephalopathy, plasma amino acid concentrations, aromatic amino acid turnover, and protein synthesis rates were determined in eight patients with alcoholic liver failure. Four patients were given the diet intravenously (iv group) (total amino acids, 60-80 g/day, BCAA content 51%, energy 2000 kcal/day) and four patients (NG group) were given a semi-elemental formulation via constant nasogastric (NG) infusion (amino acids 58 g, BCAA 43%, oligopeptides 19.5 g, energy 2000 kcal/day). The enteral diet was given at one-half strength for the first 3 days. A 10-hr constant infusion of [U-14C]phenylalanine tracer was used in four patients to measure aromatic amino acid (AA) turnover and rates of incorporation into various body proteins. Seven of the eight patients made a good clinical recovery, with reversal of encephalopathy within 3 days of dietary intervention. One became septicemic and deteriorated. While plasma bilirubin concentrations dropped, liver enzymes remained elevated. Mean nitrogen balance was negative at the beginning and positive at the end of the study, in both groups. Initial amino acid profiles demonstrated low plasma BCAA content and BCAA:AA ratios. Significant improvements occurred in the iv group by day 2 and in both groups by day 7. Isotope studies showed that, whereas aromatic amino acid oxidation remained unchanged, greater quantities were incorporated in whole body protein, albumin, transferrin, fibrinogen, and immunoglobulins.     

上海地区普外科住院患者营养风险筛查和营养支持应用调查

目的调查普通外科住院患者入院时的营养风险及住院期间的营养支持状况,分析营养风险、营养支持与临床结局的关系.方法采用营养风险筛查2002( NRS 2002),选取2009年9月至2010年4月在上海市第六人民医院普通外科的住院患者进行营养风险筛查,并调查患者2周内的营养支持状况,统计并发症发生率、住院时间和住院费用.结果 共有3000例住院患者入选,总营养风险发生率为18.5％,胃肿瘤患者营养风险最高,为48.3％.存在营养风险和无营养风险患者的营养支持率分别为44.1％和14.3％.肠外营养和肠内营养比值为1.2:1.有营养风险的患者并发症发生率、住院时间和总住院费用均高于无营养风险的患者[24.1％比14.2％,(11.1±4.8)d比(9.6±3.7)d,(12 891.5 ±4831.2)元比(9982.7±3996.4)元,P均=0.0000).在有营养风险的胃肿瘤、结直肠肿瘤和肝胆胰肿瘤患者中,应用营养支持患者的并发症发生率、平均住院时间和住院费用明显低于未用营养支持的患者(P均＜0.05).结论普通外科住院患者存在营养风险,其中胃肿瘤患者营养风险较高.营养风险与外科住院患者的临床结局有关.对有营养风险的胃肿瘤、结直肠肿瘤和肝胆胰肿瘤患者,给予营养支持可改善临床结局.     

老年性痴呆的营养支持

随着人类寿命的延长,老年性痴呆[又称阿尔茨海默病（AD）]的患病率逐渐增加,AD已经成为导致死亡的主要疾病之一,有关AD的确切病因目前尚不明确。越来越多的证据显示饮食营养因素在AD的发生发展中发挥了重要作用,对AD患者进行营养状况评估,并给予有效的营养支持,有望成为早期防治AD发生、发展的可行办法。     

呼吸内科住院患者营养风险筛查

目的调查呼吸内科住院患者的营养风险、营养不足发生率及营养支持应用状况。方法以2008年10月至12月在北京积水潭医院呼吸内科住院的100例患者为研究对象,入院后第2天和住院2周或出院时进行营养风险筛查2002（NRS2002）。营养不足判定标准为体重指数〈18．5kg／m2、血清白蛋白〈35g／或前白蛋白〈20g／L。结果住院2周或出院时NRS2002筛查结果显示,所有患者营养风险及营养不足发生率分别为59％及54％;卧床患者的营养风险和营养不足发生率分别为87．8％和82．9％,明显高于非卧床患者的32．2％和30．5％（P〈0．001）;住院时间大于2周患者的营养风险和营养不足发生率分别为75．0％和66．2％,明显高于小于2周患者的9．4％和21．9％（P〈0．001）。所有患者的营养支持率为22％,其中肠外营养与肠内营养的比例为1．2：1。结论NRS2002适用于呼吸内科住院患者的营养风险筛查。卧床和住院时间大于2周可能增加呼吸内科住院患者营养风险和营养不足的发生率。营养支持的应用在呼吸内科患者中仍不够充分和合理。     

Nutritional support in patients with systemic scleroderma

Systemic scleroderma often involves the gastrointestinal tract and can lead to significant malnutrition. Specialized home nutritional support was provided to five patients (one enteral and four parenteral) with restoration of adequate nutritional status, improved quality of life, and few metabolic or technical complications over a period of 12 to 86 months. Three patients eventually died of their disease, one was converted to an oral diet, and one patient remains dependent on total parenteral nutrition. This experience would recommend consideration of home nutritional support in patients with systemic scleroderma when the disease is relatively stable and no major organ failure is present.     

一例肝移植病人的营养支持

对1例实施肝移植的病人,术后进行30天的营养治疗。根据患者临床表现及体征将营养支持分为4个阶段,流质、半流质、软饭、普饭。通过几个阶段的胃肠营养,及早扭转了病人依赖全静脉营养,同时根据患者的临床症状及时增加某些药膳。经过营养支持,促进了病人的机体恢复和伤口愈合,病人现已存活400天以上。     

普通外科住院病人营养风险筛查和营养支持应用状况

目的:调查普通外科住院病人营养风险、营养不良和营养支持应用情况.方法:采用营养风险筛查方法(NRS2002)对普通外科625例住院病人进行营养风险筛查,统计营养不良、营养风险发生率和营养支持率,并调查病人2周内(或至出院时)的营养支持状况.结果:NRS2002完全适用率为92.5%,营养不良发生率为15.5%,营养风险...     

Nutritional support in elderly patients

There are now many studies which have found that undernutrition is prevalent and often unrecognized in patients admitted to hospitals and institutions. There is also evidence which links protein-energy undernutrition or its markers with clinical outcomes in acute and non-acute hospital settings and that nutritional supplements can improve outcomes in some of these settings. Active nutritional support following the catabolic phase of acute illness and extending during the rehabilitation period may be of particular benefit in improving nutritional intake, status and or outcome. A randomized controlled trial is therefore needed to test this hypothesis.