Nutritional support in hospitalized patients with alcoholic liver disease

The effects of a nutritional support in hospitalized patients with alcoholic cirrhosis and liver failure were studied in a controlled protocol. Thirty-six patients were included, 17 were randomly assigned to an experimental group and the rest to a control group. Experimentals received a diet aiming at 50 kcal (209 kJ)/kg bodyweight/d and 1.5 g protein/kg bodyweight/d (as proteins of high biological value). Controls received the standard diet prescribed by the attending physician. The severity of liver failure and the nutritional status on admission were similar in both groups. The measured energy intake in controls was 1813 +/- 121 kcal/d (7589 +/- 506 kJ/d) and 2707 +/- 71 kcal/d (1131 +/- 297 kJ/d) in experimentals (P less than 0.001). The protein intake in controls was 47 +/- 3.8 g/d and in experimentals 80 +/- 3 g/d (P less than 0.001). There were seven deaths during the study period (two experimentals and five controls). No differences were observed in the evolution of liver failure, hepatic encephalopathy or nutritional status between both study groups. It is concluded that a higher energy and protein intake in these patients does not have adverse effects and is associated with a non-significant reduction in mortality.     

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.     

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.     

Nutritional status of surgical patients and the relationship of nutrition to postoperative outcome.

A preoperative nutritional assessment including anthropometry, biochemical indices and global subjective assessment was performed for 127 patients admitted for elective gastrointestinal surgery. Of these, 24 were subjected to minor surgery, 65 to intermediate surgery and 38 to major procedures. Patients were followed postoperatively, recording complications or mortality. Intermediate and major surgery patients had lower triceps skinfold thickness and mid-arm circumference and greater weight loss than did minor surgery patients. Thirty-six percent of the patients suffered complications. No association was found between preoperative nutritional status and incidence of postoperative complications. Six patients died and they showed greater preoperative weight loss (21 +/? 6.5 vs 12 +/? 1.4%) and lower serum albumin levels (25 +/? 4 vs 35 +/? 1 g/l) than patients who survived complications. Global subjective assessment classified 43% of survivors as malnourished, compared to 100% of patients who died.     

Nutritional status of surgical patients and the relationship of nutrition to postoperative outcome.

A preoperative nutritional assessment including anthropometry, biochemical indices and global subjective assessment was performed for 127 patients admitted for elective gastrointestinal surgery. Of these, 24 were subjected to minor surgery, 65 to intermediate surgery and 38 to major procedures. Patients were followed postoperatively, recording complications or mortality. Intermediate and major surgery patients had lower triceps skinfold thickness and mid-arm circumference and greater weight loss than did minor surgery patients. Thirty-six percent of the patients suffered complications. No association was found between preoperative nutritional status and incidence of postoperative complications. Six patients died and they showed greater preoperative weight loss (21 +/- 6.5 vs 12 +/- 1.4%) and lower serum albumin levels (25 +/- 4 vs 35 +/- 1 g/l) than patients who survived complications. Global subjective assessment classified 43% of survivors as malnourished, compared to 100% of patients who died.     

Serum leptin levels in alcoholic liver cirrhosis: relationship with gender, nutritional status, liver function and energy metabolism

OBJECTIVE: To determine serum leptin levels in alcoholic liver cirrhosis and the relationship with gender, nutritional status, liver function, energy metabolism, inflammatory state and refeeding. SUBJECTS: Thirty-seven hospitalized alcoholic cirrhotic patients (M/F: 24/13), 27 hospitalized patients at risk of malnutrition but with normal liver function (M/F: 15/12) as control patients, and 31 healthy control subjects (M/F: 17/14) participated. DESIGN: Liver function was assessed from Child-Pugh classification; anthropometric parameters and resting energy expenditure (REE) were measured; caloric intake was evaluated over 5 days; and serum leptin and insulin were assayed. The same protocol was performed after 1 month refeeding in 22 patients. Healthy subjects were studied as controls for anthropometric parameters and serum leptin levels. RESULTS: Serum leptin levels were higher in male cirrhotic patients than in the other two male groups (P=0.0079) and in the same range in the female groups. They were higher in female than in male subjects in the three groups. In female cirrhotic patients, logarithmically transformed serum leptin levels correlated significantly with fat mass (P=0.0043), insulin levels (P=0.0072), REE (P=0.0133), bilirubin levels (P<0.0001), prothrombin time (P=0.0003) and Pugh score (P=0.0266) in simple regression analysis and with insulin levels (P=0.0137), but not with fat mass (P=0.0761), Pugh score (P=0.4472) and REE (P=0.4576) in multiple regression analysis. In the male cirrhotic and control patients, log (leptin) levels correlated with CRP (C reactive protein) (r=0.365, P=0.0223). Log (leptin) levels did not correlate with caloric intake in any of the groups. Leptin levels (P<0.05) and fat mass (P<0.02) increased with refeeding while liver function improved (P<0.01). CONCLUSION: There is a gender difference in regulation of serum leptin level in alcoholic liver cirrhosis. Insulin level is the best determinant of leptin level in female patients while inflammatory state related to alcoholic hepatitis seems to have a greater influence in male patients. Although leptin levels positively correlated with REE in female patients, there is no evidence that leptin reduces caloric intake and fat stores in these patients.     

Nutritional status and its relationship to quality of life in a sample of chronic hemodialysis patients.

OBJECTIVE: To assess the relationship between nutritional status and quality of life in a sample of chronic hemodialysis patients. DESIGN: Cross-sectional study. SETTING: Haemodialysis Units of St Vincent's and St George Hospitals, Sydney, Australia. PATIENTS: Sixty-four patients participated in the nutritional assessment, of which 53 completed the quality of life questionnaire. INTERVENTION: Nutritional status was assessed using subjective global assessment in addition to a number of anthropometric and biochemical parameters. Quality of life was assessed by means of a patient questionnaire and assessment of physical functioning. MAIN OUTCOME MEASURES: Nutrition status, 6 quality of life subscales related to general well-being, health and functioning, social and economic, psychological/spiritual well-being, and family life, employment status, income, participation in recreational/sports activities, the number of hospital admissions, days of hospitalization, and lengths of hospital stay. RESULTS: Sixty-four percent of patients were well nourished, 23% were moderately malnourished, and 13% were severely malnourished. Malnutrition was associated with poorer subjective quality after controlling for the affects of sociodemographic and medical variables. Severe malnutrition was also independently associated with poorer physical function, and resulted in significantly more hospital admissions, more days of hospitalization, and longer average lengths of hospital stay. CONCLUSION: Malnutrition is common in chronic hemodialysis patients and is associated with poorer quality of life when the degree of malnutrition becomes severe. Prospective studies are required to determine whether improving the nutritional status of these patients will result in meaningful improvements in quality of life and other medical outcomes.     

Alcohol and the liver: ethanol metabolism and the pathomechanism of alcoholic liver damage]

Ethanol is oxidized in the liver by three different enzyme systems, namely by alcohol dehidrogenase (ADH), the microsomal ethanol oxidizing system and catalase. Alcohol also undergoes a first pass metabolism in the gastric mucosa due to alcohol dehydrogenase. This first pass metabolism of ethanol is decreased in the alcoholic, in the fasted state, in the elderly and during cimetidine therapy leading to elevated alcohol blood-concentrations. Ethanol toxicity is closely related to its metabolism in the liver. Ethanol oxidation by ADH generates reducing equivalents (NADH) and acetaldehyde (AA). The elevated NADH/NAD ratio results in alterations of the intermediary metabolism of lipids, carbohydrates, proteins, purines, hormones and porphyrins. Furthermore, NADH flavours free radical production. The ethanol-associated redox changes are pronounced in the perivenular zone, since this is the area of low oxygen tension and of high ADH activity. In addition to NADH, AA exerts striking toxic effects on the hepatocyte. AA binds to cellular proteins and membranes including the mitochondria, microtubules, glutathion and various enzymes. In addition, AA and lactate stimulate collagen production in fibroblasts. AA-adducts stimulate the production of antibodies against AA-epitopes and could thus aggravate the liver injury. Chronic ethanol consumption results also in the microsomal induction of a specific ethanol-inducible form of cytochrome P--450, the cytochrome P--450IIE1 with high affinity not only to ethanol but also to some drugs (acetaminophen), procarcinogens (nitrosamines) and industrial agents (carbon tetrachloride). The interaction between ethanol metabolism and the metabolism of these compounds including vitamin A may also contribute to hepatic toxicity, since the susceptibility of the alcoholic toward those compounds is enhanced.     

Nutritional status of nursing home patients

Nutritional surveys were conducted on all 115 patients of a Medicare-approved nursing home. The techniques of nutritional assessment used included anthropometric measurements (weight/height, triceps skinfold, arm-muscle and arm circumference), biochemical and hematologic tests (serum albumin, serum transferrin, total lymphocyte count, hemoglobin, and hematocrit), and an intradermal skin test for cell mediated immunity. The prevalence of protein-calorie malnutrition (PCM) of moderate to severe degree was very high by currently used standards (weight/height, 43%; triceps skinfold, 37%; arm-muscle circumference, 85%; serum albumin, 32%; serum transferrin, 38%; and total lymphocyte counts, 22%). Anemia was found in 52% of the men and 14% of the women by normal adult standards; in addition, 19% of the patients had negative cell-mediated immunity (CMI) tests. The mortality rate during the 6 months after surveying was 13% for the immunocompetent (CMI-positive) patients and 48% for the anergic (CMI-negative). These findings confirm that PCM is prevalent in 85% of nursing home patients according to currently accepted nutritional assessment standards. In this nursing home population, 485 had marasmus, 35% had marasmus-kwashiorkor mixed syndrome, and 2% had kwashiorkor. Perhaps new standards need to be derived for such specific age groups as the elderly.     

Nutritional status of maintenance hemodialysis patients

Fat and fat-free tissues were determined in hemodialysis patients using either anthropometric measurements or indirectly from total body water (TBW) determined from urea kinetics. A very close correlation between the two methods in determining either fat or fat-free tissue (r greater than 0.8, n = 43) was shown. Twenty-two patients were followed for 2 yr. We found that fat increased while fat-free tissue decreased over that period of time. The latter appears to reflect methodological problems since both fat-free determinations depend upon TBW rather than somatic proteins. This was further confirmed by finding a proportional decrease in TBW with time, while creatinine appearance rate remained unaffected. Adherence to prescribed diet was monitored through diet records and periodic determination of urea N appearance rate during interdialysis periods. Our present studies determined body composition of hemodialysis patients and examined the relative validity of the commonly used methods. We demonstrate that no malnutrition occurs with time in patients adhering to their prescribed diet.     

老年血液透析过滤病人32例营养状况分析

随着我国人口老龄化的增加,老年终末期肾脏病（ESRD）的发病率不断增长,接受血液透析的老年人比例也呈迅速增长的趋势。由于多种原因,维持性血液透析（MHD）老年病人营养不良的发生率很高,常常导致感染、心脑血管疾病等并发症,直接影响病人的生活质量和生存率。我们应用常规血液透析（HD）及血液透析过滤（HDF）＋HD方法,自身对照研究HDF对老年血液透析病人营养状况的影响。     

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.     

维持性血液透析病人的营养状况

目的 :评价维持性血液透析 (MHD)病人的营养状况。　方法 :对 4 6例MHD病人进行膳食调查、人体测量及生化指标包括体重、肱三头肌皮皱厚度 (TSF)、上臂肌围 (AMC)、血清总蛋白 (TP)、白蛋白 (Alb)、前白蛋白 (PA)、转铁蛋白 (TF)检测 ,计算实际体重占理想体重百分比 (IBW % ) ,并作营养评价。　结果 :①MHD病人能量摄入普遍低于 12 5 .4kJ/ (kg·d) ,蛋白质摄入基本达到 1.0g/ (kg·d) ;②不同指标评估营养不良的发生率分别为IBW 9.13% ,TSF 71.74 % ,AMC 5 8.70 % ,Alb 30 .4 3% ,TF 82 .6 1%。各项指标均属正常者仅占 6 .5 2 %。　结论 :综合指标评价结果表明 ,本组病人有 93.4 8%存在不同表现和不同程度的营养不良。MHD病人进行常规的营养评价及合理的营养指导对预后有积极意义     

Nutritional status of preoperative colorectal cancer patients

Background: The present study aimed to determine the extent of malnutrition in preoperative colorectal cancer patients. Malnutrition has been shown to affect post‐operative outcome, so it would be beneficial to identify those who are malnourished or who are at risk of becoming so preoperatively. We examine whether weight loss is related to the length of stay or changes in fat free mass. Methods: Patients were enrolled consecutively from outpatients 2–4 weeks prior to surgery. Assessments included body mass index, percentage weight loss, dynamometry, Malnutrition Universal Screening Tool, Subjective Global Assessment and bioelectrical impedance. Cancer staging and hospital length of stay were recorded. Results: One hundred and thirty‐two patients were eligible and 87 enrolled. Sixty‐seven patients were weight losing and 20% had lost >10% of their usual body weight. Handgrip strength was lower in malnourished patients compared to those who had not lost weight (mean 19.4 and 27.3 kg, respectively, P = 0.013). Mean (SD) fat free mass in patients with a weight loss >10% was 39.7 (13.5) kg and, in those with <10% weight loss, was 51.9 (12.0) kg (P = 0.001). This difference was not demonstrated for fat. Conclusions: Over half of these patients had lost weight prior to surgery and one in five were malnourished. Body composition measurements demonstrated that malnourished patients had significantly less fat free mass compared to patients who were not clinically malnourished. Nutritional screening would be beneficial in this group preoperatively to identify weight‐losing patients at an early stage in the care pathway when they initially enter the secondary care system.     

Nutritional status of patients hospitalised in Poland

AIM: Screening and extended assessment of the nutritional status of patients on admission and on discharge from hospital were carried out. DESCRIPTION: The studies were carried out in four teaching hospitals, four provincial hospitals and four county hospitals in Poland. SUBJECTS: Screening examinations were carried out for 3310 randomly selected patients (every 10th patient admitted to hospital, including 1916 female cases aged from 16 to 92 y and 1394 male patients aged from 16 to 100 y). Extended examinations were carried out on 210 patients aged from 16 to 87 y (including 122 female and 88 male). MAIN ASSESSMENT PARAMETERS: Anthropometric (height, weight, body mass index (BMI), waist-to-hip ratio (WHR), arm circumference) and biochemical indices (erythrocyte count, haemoglobin concentration, white blood cell count, blood lymphocyte count and serum albumin serum concentration). The extended examinations included determination of antioxidant vitamins (A, C, E), vitamin B(12) and folic acid. RESULTS: On admission to hospital, 10.43% of the patients surveyed had a BMI below 20 kg/m(2), in 20.74% of patients serum albumin concentration was below 3.5 g/dl, indicating possible protein energy malnutrition. In addition, 21.02% had lymphocyte count below 1.5 x 10(3)/mm(3). During hospitalisation, deterioration in the nutritional status of the patient population occurred. On discharge from hospital, the percentage of patients with BMI < 20 kg/m(2) increased to 11.21% and the percentage with low blood albumin (<3.5 g/dl) increased to 28.57%. On admission, vitamin C deficiency was present in 51.8% of patients, folic acid deficiency in 32%, vitamin E deficiency in 10%, vitamin B(12) deficiency in 6.8% and vitamin A deficiency in 1.4%. Vitamin deficiencies were present equally in malnourished, overweight and obese patients. CONCLUSIONS: In patients admitted to hospitals in Poland, malnutrition risk demonstrated by BMI was observed in 10.43% of patients. On the basis of biochemical indices, increased nutritional risk was demonstrated in 21% of patients. Vitamin malnutrition was seen in the majority of patients. A significant correlation between weight, BMI, arm circumference, blood lymphocyte count and the number of days spent in hospital was observed. SPONSORSHIP: The Committee of Scientific Research and the Ministry of Health-PBZ 012-14.     

The antioxidant status of patients with either alcohol-induced liver damage or myopathy.

The antioxidant status of alcoholic patients was assessed by direct measurement of the plasma antioxidants alpha-tocopherol and beta-carotene and of selenium as a marker of glutathione peroxidase. Overall, the alcoholic group showed significant decreases in the mean plasma values of beta-carotene, zinc and selenium when compared to the control subjects. When the patients were subdivided according to their liver histology, beta-carotene showed a progressive decrease in plasma concentration with increasing liver damage, whereas alpha-tocopherol levels were only depleted in the patients with cirrhosis. There were significant decreases in the plasma concentrations of both alpha-tocopherol and selenium in all patients with alcoholic skeletal muscle myopathy, whereas patients with normal muscle biopsies showed adequate antioxidant status. Such results support a role for free radical-mediated damage in end organ injury, particularly myopathy, in alcohol misusers.     

Vitamin A utilization status in chronic alcoholic patients

The utilization status of vitamin A (retinol) (treated with oral retinol - 2500 I.U. daily (=250 micrograms) x 5 days - "OROVITE -7", Bencard, England) in 25 patients (M = 23, F = 2; mean age +/- S.D. = 43.88 +/- 12.67; range = 28-70 years), 3 out of 25 patients (12%) were found to be deficient in the vitamin and during treatment further improvement of the blood levels of the vitamin was observed in all except one elderly male patient (age 61 years) and the mean levels on admission (661.04 micrograms/l) was also slightly improved after treatment (662.84 micrograms/l). Night blindness, alcoholic liver disease and hypogonadism are commonly seen in chronic alcoholic patients. Falling plasma levels of the vitamin indicate exhaustion of its hepatic storage. It is therefore suggested that chronic alcoholics should be given vitamin A supplementation along with other polyvitamins during conventional detoxification therapy for ethanol withdrawal syndrome in order to prevent dangerous manifestations of hypovitaminosis A, such as night blindness, cancer, hypogonadism and alcoholic liver disease.     

Nutritional status in patients with dermatitis herpetiformis

Nutritional status of 86 patients with dermatitis herpetiformis (DH) was defined by anthropometric measurements and hematological and biochemical laboratory tests to establish prevalence of malabsorption and malnutrition. Anthropometric measurements in DH patients were comparable to normal control patients. Four individuals were of short stature; two had had diarrhea and failed to thrive in childhood. Abnormalities attributable to nutritional deficiency were detected in only 6 of the 86, whereas drug-associated hematological or biochemical changes were present in 36 of 55 subjects treated with dapsone or sulfapyridine. Twenty patients had hemolytic anemia or macrocytosis related to drug therapy. Only two had anemias attributable to malabsorption; one was iron deficient, the other folate deficient. Two other patients were mildly Fe deficient and two had slight folate deficiency; they lacked other stigmata of malabsorption. Drug-induced hematological and biochemical abnormalities were more common than changes that suggest nutritional disease, even though most DH patients had an enteropathy at presentation.