Aspectos fisiopatológicos da desnutrição no paciente portador de hepatopatia crônica

The nutritional alterations which result from hepatic diseases are frequent and of greatextension. The metabolism and protein synthesis are greatly affected in patients withchronic hepatopathy; these patients present poor digestion and poor absorption ofnutrients, resulting from pancreatic-biliary deficiency or associated enteropathy, witha seemingly increased energetic demand. The control of these alterations requiresconstant screening on the part of hepatologists and clinicians. Therefore, the objectiveof the present article is to review and discuss the various causes of proteic-caloricmalnutrition in chronic hepatopathy.As alterações nutricionais que decorrem das doenças hepáticas são freqüentes e degrande magnitude. O metabolismo e a síntese protéica estão gravemente afetadosem pacientes com hepatopatia crônica; estes pacientes apresentam má digestão emá absorção dos nutrientes, provocada por deficiência pancreático-biliar ou enteropatiaassociadas, com uma demanda energética que parece aumentada. O controle destasalterações requer constante vigilância por parte de hepatologistas e clínicos. Destaforma, o objetivo do presente artigo é revisar e discutir as diversas causas dadesnutrição protéico-calórica na hepatopatia crônica

Fatores associados à insuficiência renal aguda pós-transplante hepático

OBJECTIVE: To evaluate the prevalence and the risk factors associated to the development of acute renal failure in patients submitted to liver transplant, at Hospitalde Clínicas de Porto Alegre from September 1996 to September 1998.PATIENTS AND METHODS: 36 patients that developed acute renal failure after liver transplant (group 1) were compared to those who did not develop acute renalfailure after liver transplant (group 2). The following factors were analyzed prior to surgery: etiology of the renal failure, classification of Child-Pugh, diabetes mellitus,and creatinine levels; during surgery: duration of warm ischemia, duration of surgery, duration of anesthesia; CHAD type of portocaval anastomosis; and after surgery: creatinine levels, infections, need for dialysis, duration of stay at the intensive care unit, cyclosporine levels, need for another intervention, and mortality. All data were evaluated during the first 7 days after surgery, with the exception of chronic renal failure and mortality, which were evaluated during a 3-month period.RESULTS: The prevalence of acute renal failure was high (approximately 49%). The presence of previous diabetes mellitus (P=0.03), the CHAD units used duringsurgery (P=0.046), the duration of stay at the intensive care unit (P=0.01), the surgical technique (P=0,04), and the need for another intervention (P=0.02), were allsignificantly associated to the development of acute renal failure after liver transplant in our sample. There was a significant level of mortality among patients that developed acute renal failure (P=0.02).CONCLUSIONS: We concluded that acute renal failure is a significant cause of mortality among patients submitted to hepatic transplant when associated to multiplerisk factors. OBJETIVO: A prevalência e os fatores de risco associados ao desenvolvimento de IRA nos pacientes submetidos a transplante no Hospital de Clínicas de Porto Älegre (HCPA) no período de setembro/96 a setembro/98.PACIENTES E MÉTODOS: Foram comparados os pacientes que desenvolveram IRA (grupo 1) com os que não desenvolveram (grupo 2). Foram analisados no préoperatório: etiologia da isuficiência hepática, classificação de Child-Pugh, diabete melito (DM) e nível de creatinina; no trans-operatório: tempo de isquemia quente, tempo cirúrgico, tempo de anestesia, unidades de concentrado de hemácias (CHAD), tipo de anastomose porto-cava; e no pós-operatório: níveis de creatinina, infecções, necessidades de diálise, permanência na unidade de tratamento intensivo (UTI), níveis de ciclosporina, reintervenções e mortalidade. Todos os dados foram avaliados nos primeiros 7 dias de pós-operatório, com exceção de insuficiência renal crônica e mortalidade avaliados por 3 meses.RESULTADOS: A prevalência de IRA foi elevada, sendo de aproximadamente 49%. Verificamos que a presença de DM prévia (P = 0,03), unidades de CHAD utilizados no trans-operatório (p = 0,046), o tempo de internação na UTI (P = 0,001), técnica cirúrgica (P = 0,04) e necessidade de reintervenção cirúrgica (P = 0,02) estiveram associados significativamente com o desenvolvimento de IRA no pós-operatório de TxH em nossa amostra. Os pacientes que desenvolveram IRA apresentaram uma significativa mortalidade (P = 0,02). Concluímos que a IRA é uma causa significativa de mortalidade nos pacientes submetidos à transplante hepático estando associada a múltiplos fatores de risco

Aspectos fisiopatológicos da desnutrição no paciente portador de hepatopatia crônica

The nutritional alterations which result from hepatic diseases are frequent and of greatextension. The metabolism and protein synthesis are greatly affected in patients withchronic hepatopathy; these patients present poor digestion and poor absorption ofnutrients, resulting from pancreatic-biliary deficiency or associated enteropathy, witha seemingly increased energetic demand. The control of these alterations requiresconstant screening on the part of hepatologists and clinicians. Therefore, the objectiveof the present article is to review and discuss the various causes of proteic-caloricmalnutrition in chronic hepatopathy.As alterações nutricionais que decorrem das doenças hepáticas são freqüentes e degrande magnitude. O metabolismo e a síntese protéica estão gravemente afetadosem pacientes com hepatopatia crônica; estes pacientes apresentam má digestão emá absorção dos nutrientes, provocada por deficiência pancreático-biliar ou enteropatiaassociadas, com uma demanda energética que parece aumentada. O controle destasalterações requer constante vigilância por parte de hepatologistas e clínicos. Destaforma, o objetivo do presente artigo é revisar e discutir as diversas causas dadesnutrição protéico-calórica na hepatopatia crônica

NUTRITIONAL STATUS AND DIETARY INTAKE IN NON-CIRRHOTIC ADULT CHRONIC HEPATITIS C PATIENTS

BackgroundThe hepatitis C virus is one of the main causes of liver disease worldwide and may develop nutritional deficiencies.ObjectiveThe objective of this study was to assess and compare different nutritional status methods of adult patients with chronic hepatitis C virus, and to describe inadequacies in dietary intake.MethodsA cross-sectional study was conducted with adult outpatients with hepatitis C virus at a Brazilian hospital. Nutritional assessment included the 24-hour dietary recall, anthropometry (body weight, height, body mass index, triceps skinfold, mid-upper arm circumference, mid-arm muscle circumference, mid-upper arm muscle area, adductor policis muscle), Subjective Global Assessment, Royal Free Hospital Global Assessment and handgrip strength.ResultsA total of 94 outpatients (ages 30 to 76 years), was included, 46 were men. The prevalence of malnutrition as measured by the different methods was 6.4% (body mass index); 60.6% (handgrip strength), and 53.2% (Royal Free Hospital Global Assessment). There was correlation between mid-upper arm circumference and mid-arm muscle circumference (r=0.821), mid-upper arm circumference and triceps skinfold (r=0.575) and mid-upper arm circumference and mid-upper arm muscle area (r=0.781). Energy and protein intakes were below recommended levels in 49 (52.1%) and 44 (46.8%) of patients, respectively. Inadequate calcium, potassium, zinc and vitamin C intakes occurred in 92.6%, 97.9%, 63.8% and 60.6% of patients. There was an association between dietary energy and protein intake with Royal Free Hospital Global Assessment (P<0.001) and a tendency for them to be associated with handgrip strength (P=0.076 and P=0.054).ConclusionMalnutrition is frequently in hepatitis C virus patients. They have high prevalence of inadequate energy, protein and micronutrients intake, even in the absence of cirrhosis

Prevalence of diabetes mellitus and impaired glucose tolerance in patients with decompensated cirrhosis being evaluated for liver transplantation: the utility of oral glucose tolerance test

CONTEXT: Cirrhosis, diabetes mellitus, impaired glucose tolerance, insulin resistance, and protein calorie malnutrition are important issues in cirrhotic patients because they can increase the progression of liver disease and worsen its prognosis. OBJECTIVE:To determine the prevalence of diabetes mellitus, impaired glucose tolerance and insulin resistance in cirrhotic patients being evaluated for liver transplantation and their impacts on a 3-month follow-up, and to compare fasting glycemia and oral glucose tolerance test. METHODS: A cross-sectional study was performed in consecutively included adult patients. Diabetes mellitus was established through fasting glycemia and oral glucose tolerance test in diagnosing diabetes mellitus in this population. HOMA-IR and HOMA-&#946; indexes were calculated, and nutritional assessment was performed by subjective global assessment, anthropometry and handgrip strength through dynamometry. RESULTS: Diabetes mellitus was found in 40 patients (64.5%), 9 (22.5%) of them by fasting glycemia and 31 (77.5%) of them by oral glucose tolerance test. Insulin resistance was found in 40 (69%) of the patients. There was no relationship between diabetes mellitus and the etiology of cirrhosis. Protein calorie malnutrition was diagnosed in a range from 3.22% to 45.2% by anthropometry, 58.1% by subjective global assessment and 88.7% by handgrip strength. Diabetes mellitus identified by oral glucose tolerance test was related significantly to a higher prevalence of infectious complications and deaths in a 3-month period (P = 0.017). CONCLUSION: The prevalence of diabetes mellitus, impaired glucose tolerance, insulin resistance and protein calorie malnutrition is high in cirrhotic patients on the waiting list for liver transplantation. There were more infectious complications and/or deaths in a 3-month follow-up period in patients with diabetes mellitus diagnosed by oral glucose tolerance test. Oral glucose tolerance test seems to be indicated as a routine practice in this population.<br>CONTEXTO: Cirrose, diabetes mellitus, intolerância à glicose e resistência insulínica é uma associação que vem sendo discutida, bem como a desnutrição nesta população, pelo risco de pior evolução de hepatopatia. OBJETIVO: Determinar a prevalência de diabetes mellitus, intolerância à glicose e resistência insulínica e desnutrição protéico-calórica em cirróticos (vírus C+ ou -) candidatos a transplante hepático e avaliar a capacidade diagnóstica dos testes de diabetes mellitus e seu impacto na evolução em 3 meses. MÉTODOS: Estudo transversal prospectivo de pacientes consecutivos, com avaliação de diabetes mellitus por glicemia de jejum e/ou teste de tolerância oral à glicose, cálculo dos índices HOMA-IR e avaliação nutricional através da avaliação subjetiva global, antropometria e força do aperto de mão não-dominante. RESULTADOS: Sessenta e quatro virgula cinco por cento tinham diabetes mellitus, 9 (22,5%) deles foram diagnosticados por glicemia de jejum e 31 (77,5%) por tolerância oral à glicose. A resistência insulínica foi encontrada em 40 pacientes (69%). Não houve relação com a causa da cirrose. A desnutrição protéico-calórica foi encontrada em 3,22% dos pacientes através do índice de massa corporal, 45,2% por antropometria, 58,1% pela avaliação subjetiva global e 88,7% pela força do aperto de mão não-dominante. Houve associação entre diabetes mellitus diagnosticado pelo teste de tolerância oral à glicose e a maior prevalência de complicações infecciosas e/ou morte em 3 meses (P = 0,017). CONCLUSÃO: A prevalência de diabetes mellitus, intolerância à glicose, resistência insulínica e desnutrição protéico-calórica é alta em cirróticos em lista de transplante hepático. A evolução em 3 meses é pior quando há diabetes mellitus. O teste de tolerância oral à glicose teve rendimento superior à glicemia de jejum no diagnóstico de diabetes mellitus. Sugere-se o emprego rotineiro de teste de tolerância oral à glicose nesta população

Effect of Vitamin D Serum Levels and GC Gene Polymorphisms in Liver Fibrosis Due to Chronic Hepatitis C

Introduction and aim: Vitamin D has been associated with chronic liver diseases and low vitamin levels may contribute to progression of chronic hepatitis C. The aim of this study was to evaluate the influence of vitamin D serum levels and GC gene polymorphisms in the severity of liver fibrosis in patients with chronic hepatitis C genotype 1. Material and methods: Cross-sectional study that enrolled 132 adult patients with chronic hepatitis C genotype 1 attended at the outpatient Clinic of Gastroenterology Division at Hospital de Clínicas de Porto Alegre. At the time of enrollment patients had a blood withdraw for serum 25(OH)D determination and genotypic analysis of rs7041 and rs4588 polymorphisms in GC gene. None/mild fibrosis was considered as METAVIR F0, F1 and F2 and severe fibrosis as METAVIR F3 and F4. Results: Median 25(OH)D levels in the sample were 19.9 ng/mL (P25-P75: 14.0-29.4). Fifty percent of patients presented vitamin D deficiency (< 20 ng/mL). In stepwise multiple linear regression the variables associated with 25(OH)D levels were blood withdrawn in Winter/spring season, the haplotypes AT/AT + AG/AT of rs7041 and rs4588 and female sex. For evaluation of severe fibrosis, variables associated in logistic regression were age, vitamin D severe deficiency (< 10 ng/mL), glucose levels, BMI and platelets count. Conclusions: Vitamin D levels are associated with severity of liver fibrosis in chronic hepatitis C genotype 1 patients. Although the rs7041 and rs4588 GC polymorphisms are strong predictors of vitamin D levels, they do not play a direct role in liver fibrosis