Phuong-Nhi Bories

Intestinal permeability in liver cirrhosis: relationship with severe septic complications.

OBJECTIVESnPatients with liver cirrhosis are at high risk of severe septic complications such as spontaneous bacterial peritonitis (SBP) and bacteraemia. The aims of this study were to assess intestinal permeability in patients with liver cirrhosis and to search for a relationship between an impaired intestinal permeability and the occurrence of severe septic complications.nnnMETHODSnIntestinal permeability was assessed in a group of 80 cirrhotic patients (Child A, n = 13; Child B, n = 26; Child C, n = 41) and 28 healthy control subjects. A severe septic complication (bacteraemia and/or SBP) occurred in 16 patients, within 10 days before (n = 8 cases) or after (n = 8 cases) the test was performed. Lactulose (LAC) 10 g was given orally together with mannitol (MAN) 5 g, and urinary excretion rates were determined.nnnRESULTSnUrinary mannitol excretion (MAN%) was lower while the LAC/MAN ratio was higher in patients than in control subjects (P < 0.001); these abnormalities were more marked in Child C patients (Child C patients vs control subjects: MAN%, 8.20 +/- 0.79 vs 14.59 +/- 0.58, P < 0.001; LAC/MAN, 0.066 +/- 0.026 vs 0.017 +/- 0.001, P < 0.02). When compared with non-infected patients, septic patients had a lower MAN% and an increased LAC/ MAN ratio (5.45 +/- 1.12 vs 9.83 +/- 0.87, P < 0.02; 0.130 +/- 0.063 vs 0.029 +/- 0.005, P < 0.02).nnnCONCLUSIONnAlthough the main mechanism involved in the decrease in MAN% is likely a reduction in area of the intestinal absorptive surface, these results argue in favour of an increased intestinal permeability in liver cirrhosis, especially in patients with severe infectious complications. The impairment of intestinal function barrier may contribute to severe septic complications in these patients.

Validation of body mass index for the diagnosis of malnutrition in patients with liver cirrhosis

OBJECTIVESnSimple clinical tools are needed to detect malnutrition in cirrhotic patients. We have validated optimal body mass index (BMI) cut-offs for the diagnosis of malnutrition in accordance with the importance of ascites.nnnMETHODSnBMI, mid-arm muscle circumference (MAMC) and triceps skinfold thickness (TST) were measured before paracentesis in study (SP) and validation (VP) populations of 875 and 294 cirrhotic patients, respectively with no ascite (NA), mild (MA), tense ascites (TA) (NA/MA/TA: SP: 327, 270, 278; VP: 111, 69, 114). Preserved nutritional status (SP: 259; VP: 93), malnutrition including severe and moderate malnutrition (SP: 251 and 365; VP: 92 and 109) were defined from MAMC and TST measurements.nnnRESULTSnOptimal BMI cut-off values were 22, 23 and 25 kg/m2 in NA, MA and TA patients, respectively. In the whole SP and VP, sensitivities of these cut-offs were 86.2% and 89.1%, respectively; the corresponding negative predictive values (NPV) for the diagnosis of severe malnutrition were 92.3% and 93.2%; specificities and positive predictive values (PPV) were 87.7% and 89.9%, 92.7% and 93.6%, respectively for the diagnosis of malnutrition. In the entire VP, peripheral oedema did not change sensitivity and NPV of BMI cut-offs for the diagnosis of severe malnutrition and tended to increase specificity and PPV for the diagnosis of malnutrition. 96.7% of the malnourished TA patients in the VP before paracentesis were correctly identified after removal of ascites.nnnCONCLUSIONnBMI is a reliable parameter to detect malnutrition in cirrhotic patients with the above mentioned cut-offs. Peripheral oedema and removal of ascites do not affect its diagnostic performance.

Nutritional status and energy expenditure in elderly patients with recent hip fracture during a 2-month follow-up.

A 2-month follow-up of nutritional status was performed in forty elderly patients with recent hip fracture. Patients were nutritionally assessed on admission to our rehabilitation unit (day 0), then monthly (day 30, day 60) by measurement of resting energy expenditure (REE), anthropometric, impedance and biological variables. Patients were defined as undernourished (n 13) or normally nourished (n 27) on the basis of mid-arm circumference (MAC) and triceps skinfold thickness (TST) measurements. Seven patients recovered a walking autonomy and were discharged from the hospital before day 30 (group I) whereas thirteen patients were discharged after day 30 (group II); twenty patients remained in the study at day 60 (group III). MAC and TST decreased in normally nourished patients from group III throughout the study whereas they did not change in group II or in undernourished patients from group III. REE values in relation to fat-free mass were increased compared with normal values and were similar in the three groups on day 0; they did not change during the study. Daily energy intake in relation to body weight was higher in group I and increased in group II and in undernourished patients from group III throughout the study. In contrast, it was below the recommended value at day 0 and it did not significantly improve in normally nourished patients from group III. Serum albumin, transthyretin and transferrin levels on day 0 were below reference intervals in the three groups. Albumin levels increased in group III throughout the study. Inflammatory proteins decreased in groups II and III, with C-reactive protein levels returning to normal values in group II by day 30 and in group III at day 60, while orosomucoid levels did not become completely normal over this period. Our findings indicate no improvement in nutritional status in undernourished patients after surgery for recent hip fracture, despite an adequate energy intake. An insufficient spontaneous energy intake for normally nourished patients was associated with a delayed favourable outcome resulting in a prolonged duration of hospitalization. A hypermetabolic state persisted during the 3 months after surgery.

Oral candidiasis and nutritional deficiencies in elderly hospitalised patients

The prevalence of oral candidiasis and its association with malnutrition in terms of protein-energy malnutrition and mineral and vitamin depletion were evaluated in ninety-seven hospitalised older adults aged 82.1 (SD 8.6) years. Patients underwent a complete oral examination with microbiological investigation on admission to our geriatric rehabilitation unit. Patients were assessed nutritionally by evaluation of dietary intake and measurement of anthropometric variables, serum nutritional proteins, ferritin, Zn, folate, vitamins B12 and C. The prevalence of oral candidiasis was 37% (n 36); the proportion of patients with BMI <20 kg/m(2) was 32% (n 31). The nutritional status of the population was studied by comparing two groups defined according to the absence (group I; n 61) or presence (group II; n 36) of oral candidiasis. The two groups did not differ on the basis of BMI and mid-arm circumference. However, group II had a smaller leg circumference, lower daily energy and protein intakes, lower albumin and transthyretin levels. Patients successfully treated with fluconazole increased their intake on day 30. The proportion of patients with hypozincaemia (<12.5 micromol/l) and vitamin C deficiency (<0.7 mg/l) was higher in group II. Treatment with antibiotics, poor oral hygiene, denture wearing, and vitamin C deficiency appeared as the most significant independent risk factors associated with oral candidiasis. The present findings show that oral candidiasis appears to be related to malnutrition and results in mucosal lesions that have a negative impact on energy intake, which may subsequently worsen nutritional status.

Aging, energy expenditure and nutritional status : evidence for denutrition-related hypermetabolism

Resting energy expenditure (REE) and nutritional status have been evaluated in 39 elderly inpatients (mean age 84.0 +/- 6.9 years). The nutritional status declined with aging as shown by significant negative correlations between age and, respectively, weight (p < 0.001), fat free mass (FFM) (p < 0.01) and body mass index (BMI) (p < 0.01). The best prediction for REE when considering the whole population was given by FFM (p < 0.001). Increased REE was observed in patients after recent surgery, related to an inflammatory state, as shown by increased plasma levels of C-reactive protein and orosomucoid. Irrespectively of the inflammatory state, REE was also found to be related to the nutritional status: patients who showed a BMI < 20 had higher REE than patients with a BMI > 20 (28.4 +/- 1.3 vs. 22.1 +/- 0.7 kcal/kg of body weight; p < 0.001; 35.7 +/- 1.6 vs. 30.9 +/- 1.0 kcal/kg of FFM; p < 0.02). These results increasingly suggest that elderly patients may suffer from denutrition relevant to hypermetabolism.

The thermogenic and metabolic effects of food in liver cirrhosis: Consequences on the storage of nutrients and the hormonal counterregulatory response

The thermogenic effect of food and the rates of oxidation and storage of nutrients were evaluated by indirect calorimetry in 10 cirrhotic patients and seven normal controls for a 6-hour period, after they had consumed a standard meal supplying 15 kcal/kg body weight with 15%, 30%, and 55% protein, fat, and carbohydrate calories, respectively. Although the thermogenic response to food was not significantly lower in patients than in controls (51.6 +/- 13.5 v 72.2 +/- 8.8 kcal/6 h), patients exhibited a delayed and blunted increment of energy expenditure after the meal intake (P less than .025). The greater part of the glucose load was oxidized in patients (70.2 +/- 3.9% v 50.4 +/- 3.9% in controls; P less than .01), suggesting a defective glucose storage as glycogen. This result could be related to insulin resistance, which was evidenced by a large increase in glucose and insulin levels after the meal intake in patients (P +/- .001). Conversely, lipid oxidation was sharply reduced and de novo lipogenesis occurred in patients, so that the rate of lipid storage was increased. The profiles of circulating levels of catecholamines, thyroid hormones (free thyroxine [FT4] and triiodothyronine [T3]), and glucagon were assayed during the test. Norepinephrine and glucagon levels remained higher in patients throughout the test (P less than .001), whereas thyroid hormones stayed in the same range in the two groups. After an initial increase, glucose levels decreased sharply, inducing an activation of counterregulatory hormones, glucagon, and notably, epinephrine, for which the increment was correlated with the decrease of glucose (r = -.917; P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Combined polymorphisms of tumour necrosis factor alpha and interleukin-10 genes in patients with alcoholic hepatitis.

Objectives The development and progression of alcoholic hepatitis are controlled by an extensive cytokine network which involves pro-inflammatory and anti-inflammatory cytokines. Genetic variations determining production of these cytokines have been described and the susceptibility to the disease may be determined by an imbalance in the expression of several candidate genes. Methods We have studied biallelic single nucleotide polymorphisms at positions (−308) and (−238) in the promoter region of the pro-inflammatory tumour necrosis factor alpha (TNF-&agr;) and at positions (−1082) and (−592) in the promoter of anti-inflammatory interleukin-10 (IL-10) in 134 patients with severe biopsy-proven alcoholic hepatitis and 145 healthy subjects. Results The frequency distribution of isolated cytokine genotypes did not differ between the two groups. The combination of at least one A308 or A238 allele for TNF-&agr;, associated with a TNF-&agr; high-producer phenotype, and one A592 or A1082 allele for IL-10, associated with an IL-10 low-producer phenotype, was less frequent in patients (20.9 vs 33.8%, P=0.016, OR (95% CI)=0.52 (0.30–0.89)). The same combination in patients was associated with a higher risk of septic complications (32.5 vs 16.0%, P=0.031, OR (95% CI)=1.79 (1.07–6.00)) but not with in-hospital mortality. Conclusions We have not found any relationship between the isolated polymorphisms and the risk of alcoholic hepatitis. Moreover, the imbalance between the pro-inflammatory and anti-inflammatory responses leading to high TNF-&agr; production and low IL-10 was uncommon in alcoholic hepatitis. However, patients with this particular genotype appeared more susceptible to severe septic complications.

Prognostic value of dietary intake and inflammation on survival in patients with advanced cancer: relationship with performance status, pain, and digestive disorders.

Background: Malnutrition is common in patients with advanced cancer and associated with worse prognosis. Furthermore, these patients frequently suffer from digestive symptoms and pain. The aim of this study was to define short-term predictors of survival to help the development of an adequate nutritional care plan. Methods: Seventy-one patients (36 males and 35 females) (mean age, 68.7 ± 12.3 years) with advanced cancer entered the study. The following two groups of patients were defined: Group I (n = 34) was composed of patients who died within 3 mo, and Group II (n = 37) included patients who were alive by the end of the study. Nutritional status by means of anthropometric variables and serum proteins were assessed on Day 0 and 1 mo later. Dietary intake, performance status, pain, and digestive symptoms were recorded on admission and, thereafter, weekly during 1 mo. Results: The two groups did not differ in terms of age, sex, tumor distribution, weight loss, anthropometric variables, pain score, and digestive symptoms. On the other hand, Group I had lower energy intake (964 ± 101 vs 1,667 ± 85 kcal/day, P < 0.001), albumin and transthyretin levels (respectively, 29.2 ± 0.9 vs 34.9 ± 0.6 and 0.15 ± 0.01 vs 0.24 ± 0.02 g/l, P < 0.001) and a higher score indicating a poorer performance status (P < 0.001), higher Prognostic Inflammatory and Nutritional Index (PINI) (88.8 ± 23.4 vs 12.6 ± 12.6 ± 4.4, P < 0.01), serum C-reactive protein (98 ± 17 vs 33 ± 7 mg/l, P < 0.001), and orosomucoid (1.92 ± 0.09 vs 1.46 ± 0.08 g/l, P < 0.001) levels throughout the study period. Energy intake correlated negatively with performance status (P < 0.001) and pain scores (P < 0.01) and PINI (P < 0.01). Energy intake < 660 kcal/day and PINI > 66, which are mean value ± 2 SD in Group II, had 97% specificity to predict death. Conclusion: Three factors affected prognosis, i.e., inflammation, performance status, and energy intake. The latter two may benefit from amelioration of pain and digestive symptoms. PINI and energy intake may provide indication to identify patients close to death from those who could receive a nutritional support and active palliative therapy.

Évaluation de l’état nutritionnel de 57 malades âgés hospitalisés : influence de la pathologie causale

Resume Propos. – Le but de ce travail est d’apprecier l’etat nutritionnel de patients âges, hospitalises en moyen sejour et comparer le bilan nutritionnel des sujets operes d’une fracture du col femoral a celui de malades presentant un probleme medical en cours de traitement. Methodes. – Le bilan nutritionnel comprenait des mesures anthropometriques, biologiques et de la ration alimentaire. Trente-sept malades ont ete operes d’une fracture du col femoral (groupexa0I) et 20xa0malades presentaient une pathologie medicale en cours de traitement (groupexa0II). L’etat nutritionnel des patients operes a ete d’une part compare a celui de malades non operes a leur admission dans le service (j0) et, d’autre part, reevalue 30xa0jours apres le debut de leur hospitalisation (j30). Resultats. – Aucun parametre anthropometrique ou biologique (albumine, prealbumine, transferrine) n’etait significativement different entre les patients operes et non operes. La ration rapportee au poids etait comparable dans les deux groupes (31xa0kcal/kg). Les taux de proteinexa0C reactive et d’orosomucoide etaient augmentes dans les deux groupes. Les patients operes avaient un taux d’orosomucoide significativement superieur a celui des patients non operes (1,50xa0± 0,4 versus 1,14xa0± 0,4xa0g/Lxa0; pxa0= 0,002). Le suivi nutritionnel de 31xa0malades operes montrait une diminution significative de l’epaisseur cutanee tricipitale et de la circonference brachiale (respectivement pxa0= 0,02 et pxa0= 0,007) et de l’orosomucoide (pxa0= 0,003) entre j0 et j30 malgre une augmentation de la ration alimentaire. Conclusions. – Vingt-huit pour cent des malades sont denutris a leur admission dans le service et un syndrome inflammatoire est present chez tous nos malades, trois semaines apres une pathologie aigue. Ce syndrome inflammatoire est plus important dans le groupe de malades operes et il persiste pendant plusieurs semaines apres l’intervention chirurgicale.