Mathias Plauth

Prevalence of Malnutrition in Hospitalized Medical Patients: Impact of Underlying Disease

Background/Aims: Malnutrition is common among hospitalized patients. We investigated whether certain diseases predispose more frequently for malnutrition than others. Methods: Nutritional state was assessed by clinical scores, anthropometry and bioimpedance analysis in 502 consecutively admitted patients in the departments of internal medicine in two hospitals in Berlin (n = 300, university hospital; n = 202, district hospital). The prevalence of malnutrition was compared in patient groups with a different diagnosis. Results: Malnutrition was present in 24.2% of all patients. A clear association between diagnoses and malnutrition was found: the prevalence of malnutrition was significantly higher in malignant than in non-malignant diseases (50.9 vs. 21.0%, p < 0.0001). High prevalence rates >30% were observed in subgroups of patients with inflammatory bowel diseases, chronic heart failure and benign lung diseases. Patients with gastrointestinal diseases, however, were not more frequently malnourished than other medical patients (28.8 vs. 22.0%). Malnourished patients were significantly older (70.0 ± 13.6 vs. 58.3 ± 15.6 years, p < 0.0001) and had a 40% longer hospital stay (13.1 ± 8.1 vs. 9.3 ± 6.8 days, p < 0.0001) than well-nourished patients. Conclusions: Patients with malignancies, inflammatory bowel disease, chronic heart failure and benign lung diseases need special attention due to the high prevalence of malnutrition.

Long-term treatment of latent portosystemic encephalopathy with branched-chain amino acids : a double-blind placebo-controlled crossover study

This trial was undertaken to assess the safety and efficacy of long-term oral supplementation with branched-chain amino acids as an adjunct to conventional therapy in patients with stable cirrhosis and latent encephalopathy. Latent encephalopathy was diagnosed by psychometric testing, used to assess automobile driving capacity. Seventeen patients with impaired driving capacity received either branched-chain amino acids or placebo for 8 weeks before being crossed over to the other regimen for an equal period. Branched-chain amino acids but not placebo significantly improved psychomotor disturbances (p < 0.01) and driving capacity (p < 0.002). No adverse reactions were observed. We conclude that long-term branched-chain amino acid supplementation is well tolerated and effective in the treatment of impaired automobile driving capacity associated with latent portosystemic encephalopathy.

White-Light or Narrow-Band Imaging Colonoscopy in Surveillance of Ulcerative Colitis: A Prospective Multicenter Study

BACKGROUND & AIMS Early detection of neoplastic lesions is essential in patients with long-standing ulcerative colitis but the best technique of colonoscopy still is controversial. METHODS We performed a prospective multicenter study in patients with long-standing ulcerative colitis. Two colonoscopies were performed in each patient within 3 weeks to 3 months. In white-light (WL) colonoscopy, stepwise random biopsy specimens (4 biopsy specimens every 10 cm), segmental random biopsies (2 biopsy specimens in 5 segments), and targeted biopsy specimens were taken. In NBI colonoscopy, segmental and targeted biopsy specimens were taken. The sequence of WL and NBI colonoscopy was randomized. RESULTS In 36 of 159 patients enrolled (22.6%), 54 lesions with intraepithelial neoplasia (IN) were found (51 low-grade, 3 high-grade). In WL colonoscopy we found 11 IN in stepwise biopsy specimens, 4 in segmental biopsy specimens, and 15 in targeted biopsy specimens. In NBI colonoscopy 7 IN were detected in segmental biopsy specimens and 24 IN were detected in targeted biopsy specimens. Almost all IN were found with one technique alone (κ value of WL vs NBI, -0.86; P < .001). Statistically equivalent numbers of IN were found in NBI colonoscopy with targeted and segmental biopsy specimens as in WL colonoscopy with targeted and stepwise biopsy specimens, but with fewer biopsy specimens (11.9 vs 38.6 biopsy specimens, respectively; P < .001), and less withdrawal time was necessary (23 vs 13 min, respectively; P < .001). CONCLUSIONS Stepwise biopsy specimens are indispensable in WL colonoscopy. The combination of targeted and segmental biopsy specimens in the NBI technique is as sensitive as targeted together with stepwise biopsy specimens in WL colonoscopy, but requires fewer biopsy specimens and less time. The highest sensitivity should be reached by combining the WL and NBI techniques by switching between the modes.

Effects of dexamethasone on glutamine metabolism in the isolated vascularly perfused rat small intestine

SummaryPost-stress metabolism is associated with a large glutamine (Gln) efflux from muscle and an increased Gln utilization by the small intestine. Both appear to be modulated by corticosteroids. The present investigation was performed to better characterize the mechanism of corticoid action on Gln metabolism in an isolated preparation of vascularly perfused rat small intestine. In all perfusions, a synthetic perfusate free from blood components was used with only 0.6 mM Gln and 10 mM glucose as substrates. Irrespective of dexamethasone concentrations in the vascular perfusate (none, 0.25 mg l−1, or 2.5 mg l−1), isolated intestines from normal rats exhibited unchanged extraction rates of Gln (−85±8, −89±10, and −87±16 nmol min−1 g−1) and unchanged production rates of alanine (43±9, 40±7, and 51±5 nmol min−1 g−1) and ammonia (49±15, 45±13, and 54±13 nmol min−1 g−1).Similarly, when intestines were vascularly perfused 2 or 9 days after dexamethasone injection (0.45 mg kg−1 BW), net Gln uptake also remained unchanged (−88±16 and −84±11 nmol min−1 g−1). There was, however, a shift in nitrogenous products of Gln metabolism from ammonia (−31% and −38%) to alanine (+16% and +64%). Thus, the failure of dexamethasone to increase Gln uptake in the isolated rat intestine may indicate that rather than acting directly on the mucosa, dexamethasone could regulate intestinal Gln consumption in vivo by indirect mechanisms possibly involving extramucosal tissues. Dexamethasone pretreatment may modulate the pattern of nitrogenous products in portal venous blood presented to the liver and thus support enhanced nitrogen loss through ureagenesis by metabolic cooperation between gut and liver.

Branched-chain amino acids in liver disease: new aspects of long known phenomena.

Purpose of reviewTo provide an overview of findings on the role of branched-chain amino acids (BCAAs) in the pathophysiology, pathobiochemistry, and treatment of liver cirrhosis and its complications that have been published since or were not included in the last review on this topic in 2007 in this journal. Recent findingsThere has been continued interest in the potential of oral BCAA supplements in improving energy metabolism, nitrogen metabolism, carbohydrate metabolism, insulin resistance, severity of liver disease, serum albumin levels, quality of serum albumin, or postoperative complication rates. Unfortunately, many trials suffer from lacking or inadequate controls or small sample size. In a fine example of scientific perseverance, Dutch researchers uncovered the long-known phenomenon of ingested blood being highly comagenic in patients with cirrhosis to be due to the low biologic value of blood protein. The absence of isoleucine and the abundance of leucine in the hemoglobin molecule by way of BCAA antagonism leads to impaired protein synthesis and azotemia paving the way for hepatic encephalopathy. SummaryRecognizing hypoisoleucinemia and BCAA antagonism following gastrointestinal bleeding, and its successful treatment by isoleucine infusion has advanced our understanding of the role of BCAA in liver cirrhosis.

Use of an artificial oxygen carrier in isolated rat liver perfusion : first demonstration of net glucose uptake at physiological portal glucose concentrations using a hemoglobin-free perfusate

SummaryA defect in isolated perfused rat-liver (IPRL) preparations has been proposed to explain discrepancies between in vivo and in vitro findings regarding hepatic glucose metabolism. The aim of the present study was to investigate whether a preparation of IPRL using a synthetic hemoglobin-free perfusate was capable of net glucose uptake and glycogen deposition at physiological portal substrate concentrations. Livers from fed anaesthetized rats were perfused in a recirculating system using a fluorocarbon emulsion as artificial oxygen carrier. Depending on the prevailing glucose concentration, livers exhibited net glucose uptake or release with a threshold value of 5.5–6.0 mM glucose. Net glucose uptake was associated with net glycogen deposition (+0.23 to +0.59 μmol C6 min−1g−1). From 5.8 mM (n=3) and 10.0 mM (n=8), initial concentration glucose levels fell to 5.3±0.2 mM after 210 min (n=3) and 6.3±0.9 mM after 120 min (n=8), respectively. This was equivalent to a net glucose uptake of −0.16 and −0.45 μmol min−1g−1. Anoxia reversibly switched hepatic glucose balance from net uptake (−0.42 μmol min−1g−1) to release (+0.69 μmol min−1g−1) followed by net uptake (−0.50 μmol min−1g−1) after reinstitution of aerobic conditions.We conclude that the composition of perfusion media might play a pivotal role for studies of glucose metabolism in the isolated perfused rat liver. In our experimental model, using a hemoglobin-free synthetic medium, net glucose uptake was readily demonstrated at physiological portal substrate concentrations similar to the in vivo situation.

Glutamine-dependence of rat enterocyte functions as assessed in cell cultures

Glutamine has been shown to be of critical importance for various cell functions (1-5). A number of mammalian cells in culture including fibroblasts (6), HeLa cells (7) and other tumour cell lines exhibit a positive correlation between cell growth and glutamine support. Zetterberg (6) demonstrated the dependence on glutamine of DNA/ RNA replication and cell multiplication in fibroblasts. In non-proliferating cells, i.e. primary cell cultures, the importance of glutamine as an essential substrate has not yet been established. However, studies on cell differentiation are contradictory: Beaulieu (8) reported a permissive effect of glutamine on differentiation of foetal small intestine, whereas in Viallard’s study differentiation of a human colon cancer cell line occurred only in the absence of glutamine (9). Under physiological conditions, the small intestine exhibits a high net glutamine utilisation in many species, including man, exceeding that of all other organs measured (for review, see (10,ll)). Apart from its relevance as a metabolic fuel for intestinal epithelial cells, only few data are available on the glutamine-dependence of characteristic enterocyte functions (12-15). The experimental use of glutaminase as an anti-neoplastic agent resulted in a decrease of serum glutamine to undetectable levels and acute necrotising colitis as a severe side-effect (16). Conversely, glutamine exerted a beneficial effect on intestinal mucosa after TPN induced atrophy (17, 18) or methotrexate induced enterocolitis (19). We therefore investigated the glutamine dependence of various intestinal cell functions in shortterm cell cultures of freshly isolated differentiated enterocytes of adult rats.

Dipeptide metabolism in the isolated perfused rat small intestine

The purpose of the present study was to investigate the utilisation of vascularly administered leucyl-leucine (Leu-Leu), alanyl-glutamine (Ala-Gln) and glycyl-glutamine (Gly-Gln) by the isolated vascularly perfused rat small intestine. Fractional extraction rates were 49%, 35.5%, and 12% for Leu-Leu, Ala-Gln, and Gly-Gln (0.15mM) corresponding to a net uptake of -63.5, -31.5, and -17 nmol/min/g wet weight. Nitrogen metabolism in terms of glutamine uptake and release of alanine and ammonia was not different when perfusion with dipeptides or with free amino-acids were compared. No soluble dipeptidase activity was released into the plasma- and cell-free synthetic vascular perfusate. No dipeptide could be recovered from the luminal perfusate. Considering the high fractional extraction rate for Leu-Leu, it is conceivable that dipeptide assimilation may occur also in extramucosal gut tissue. Although dipeptide transport cannot be excluded, dipeptide assimilation in small intestine may involve membrane bound peptidase(s), as in liver.

EASL Clinical Practice Guidelines on nutrition in chronic liver disease

Недостаточность питания — частое осложнение цирроза печени, связанное с прогрессированием печеночной недостаточности, а также с высокой частотой развития других осложнений (инфекции, печеночная энцефалопатия и асцит). В последние годы распространение ожирения привело к увеличению количества случаев цирроза, связанных с неалкогольным стеатогепатитом. Недостаточность питания, ожирение и саркопеническое ожирение могут ухудшить прогноз пациентов с циррозом печени и снизить их выживание. Таким образом, наблюдение за состоянием питания и применение мер его коррекции имеют решающее значение в диагностике и лечении больных с хроническим заболеванием печени. Приведен обзор современных знаний в области питания при хронических заболеваниях печени. Рассмотрены способы скрининга и оценки питания, а также принципы его коррекции. Представлены рекомендации при печеночной энцефалопатии, больным циррозом печени с заболеваниями костей, пациентам, которые перенесли хирургическое вмешательство на печени или трансплантацию, а также больным циррозом печени в критических состояниях.A frequent complication in liver cirrhosis is malnutrition, which is associated with the progression of liver failure, and with a higher rate of complications including infections, hepatic encephalopathy and ascites. In recent years, the rising prevalence of obesity has led to an increase in the number of cirrhosis cases related to non-alcoholic steatohepatitis. Malnutrition, obesity and sarcopenic obesity may worsen the prognosis of patients with liver cirrhosis and lower their survival. Nutritional monitoring and intervention is therefore crucial in chronic liver disease. These Clinical Practice Guidelines review the present knowledge in the field of nutrition in chronic liver disease and promote further research on this topic. Screening, assessment and principles of nutritional management are examined, with recommendations provided in specific settings such as hepatic encephalopathy, cirrhotic patients with bone disease, patients undergoing liver surgery or transplantation and critically ill cirrhotic patients.

12. Nutrition in Liver Disease

Nutritional status and liver disease influence each other. Liver function is compromized by malnutrition and this impairment can be overcome by nutritional intervention. Depending on disease severity, especially chronic liver disease leads to malnutrition which is an indicator of a poor prognosis. Both presence and degree of malnutrition can be diagnosed clinically without the need for techniqual equipment. In severe acute liver disease, indication and practice of nutritional therapy are not different from those in critically ill patients due to other etiology. In chronic liver disease, spontaneous food intake often is inadequate and frequently there is protein malnutrition. In a stepwise approach individualized dietary counselling, supplemental oral sip feeding, enteral tube feeding or parenteral nutrition as a second line option should be used. Nutritional therapy ensuring adequate provision of energy and protein can improve morbidity and mortality.