Wilza Arantes Ferreira Peres

Vitamin A deficiency in patients with hepatitis C virus-related chronic liver disease

Hepatitis C virus (HCV) infection is associated with oxidative stress and vitamin A possesses antioxidant activity. The objective of the present study was to investigate vitamin A nutritional status in chronic hepatitis, liver cirrhosis and hepatocellular carcinoma (HCC), according to biochemical, functional and dietetic indicators correlating these findings with liver function, liver damage and death. Vitamin A nutritional status was analysed by serum retinol levels, dietetic indicators and functional indicators. A total of 140 patients with HCV-related liver disease were enrolled. Vitamin A deficiency was detected in 54·3 % of all patients, and there was a progressive drop in serum retinol levels from chronic hepatitis C patients towards cirrhosis and HCC patients. Increased total bilirubin, liver transaminases and prothrombin time, presence of hepatic encephalopathy and ascites were related to reduced serum retinol levels, and values ≤ 0·78 μmol/l of serum retinol were associated with liver-related death. A high prevalence of inadequate intake of vitamin A was observed in all stages of chronic liver disease. The functional indicator was not an adequate parameter for evaluating the vitamin A nutritional status. Therefore, serum retinol concentration is related to severity of the disease, liver complications and mortality. The effectiveness of nutritional counselling and measures of intervention in this group in improving vitamin A nutritional status should be examined further in a controlled study.

Phase angle as a nutritional evaluation tool in all stages of chronic liver disease

INTRODUCTION Malnutrition is commonly and frequently under-diagnosed in clinical settings in patients with chronic liver disease (CLD) due to the limitations of nutritional evaluation methods in this population. We hypothesized that the bioelectrical impedance analysis derived phase angle (BIA-derived PhA) might be considered as a nutritional indicator in CLD since it represents either cell death or malnutrition characterized by changes in cellular membrane integrity. OBJECTIVE The aim of this study was to evaluate the BIA-derived PhA as a nutritional evaluation tool in all stages of CLD, including chronic hepatitis, liver cirrhosis and hepatocellular carcinoma (HCC). Liver-related death and survival were evaluated. METHODS A total of 66 patients were enrolled in a cross-sectional study. For the nutritional diagnosis, mid-arm circumference (MAC), triceps skinfold thickness (TST), mid-arm muscle circumference (MAMC) and Subject Global Assessment (SGA) were evaluated. Biochemical and clinical evaluations were performed. RESULTS Our results showed that PhA was higher in well-nourished patients, according to SGA and in the patients without hepatic encephalopathy. PhA correlated significantly with MAMC, MAC and albumin and was inversely correlated with age. No correlation was found between PhA values and the Child-Pugh score and ascites. PhA was strongly associated with survival and PhA ≤ 5.18º with relative risk increase of 2.5 for death. CONCLUSIONS We conclude that the BIA-derived PhA is a relevant nutritional evaluation tool in chronic hepatitis, liver cirrhosis and HCC and the role of PhA in the prediction of survival in CLD should be examined further in a controlled study.

Assessment of the Relative Dose-Response Test as Indicators of Hepatic Vitamin A Stores in Various Stages of Chronic Liver Disease

Hepatic vitamin A stores should be the best early indicator of vitamin A status because more than 90% of total body vitamin A is stored in the liver. The objective of the present study was to evaluate the hepatic vitamin A stores in all stages of chronic liver disease (CLD), including chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma (HCC). One hundred forty-four patients (age 55.34 ± 9.38 years) were evaluated in a cross-sectional study. Vitamin A nutrition status was analyzed by serum retinol levels and relative dose-response (RDR) method. Patients with cholestasis were excluded from the sample group. Biochemical, clinical, and anthropometric evaluations were performed. Vitamin A deficiency (VAD) was detected in 51.4% of all patients. Patients with adequate levels of serum retinol presented adequate liver vitamin A reserves; in contrast, nearly half the patients with low serum retinol levels presented adequate levels of retinol in the liver, although none of the patients with hepatitis had this condition. Therefore, the effectiveness of the RDR method for evaluating vitamin A nutrition status was limited in patients with cirrhosis and HCC, perhaps due to the advanced age of these patients, since those in the chronic hepatitis group, who were younger, responded adequately to the test. Thus, the RDR method should be modified when applied to later stages of CLD, considering the time and dose of retinyl palmitate supplementation, as VAD may be a risk factor for the progression of the disease.

Association between non-alcoholic fatty liver disease and liver function/injury markers with metabolic syndrome components in class III obese individuals

OBJECTIVE To investigate the association between non-alcoholic fatty liver disease (NAFLD) and liver function/injury markers with components of metabolic syndrome (MS) in class III obese individuals. METHODS The study population consisted of 144 patients with class III obesity (body mass index [BMI] > 40 kg/m²). MS was diagnosed according to the National Cholesterol Education Program - Adult Treatment Panel III (NCEP ATP III) criteria, by determining the lipid profile, blood glucose and basal insulin. Liver function/injury markers were also quantified. Insulin resistance (IR) was measured by HOMA-IR and NAFLD diagnosis was established by magnetic resonance imaging (MRI). Statistical calculations were performed by SPSS version 13.0. The association was assessed by the Mann-Whitney and Chi-square tests, with a level of significance set at 5%. RESULTS There was a significant association between the diagnosis of MS and NAFLD (χ² = 6.84, p = 0.01). As for the diagnostic components of MS, there was a positive and significant association between HDL-C (p = 0.05), waist circumference (p < 0.05) and hypertension (χ² = 4.195, p = 0.041) with NAFLD. HOMA-IR (p < 0.001) also showed a positive association with liver disease. CONCLUSION A positive and significant association between NAFLD and components of metabolic syndrome in class III obese individuals was observed, suggesting the need and importance of monitoring these components for NAFLD screening.

Associação entre doença hepática gordurosa não alcoólica e marcadores de lesão/função hepática com componentes da síndrome metabólica em indivíduos obesos classe III

OBJECTIVE: To investigate the association between non-alcoholic fatty liver disease (NAFLD) and liver function/injury markers with components of metabolic syndrome (MS) in class III obese individuals. METHODS: The study population consisted of 144 patients with class III obesity (body mass index [BMI] > 40 kg/m2). MS was diagnosed according to the National Cholesterol Education Program - Adult Treatment Panel III (NCEP ATP III) criteria, by determining the lipid profile, blood glucose and basal insulin. Liver function/injury markers were also quantified. Insulin resistance (IR) was measured by HOMA-IR and NAFLD diagnosis was established by magnetic resonance imaging (MRI). Statistical calculations were performed by SPSS version 13.0. The association was assessed by the Mann-Whitney and Chi-square tests, with a level of significance set at 5%. RESULTS: There was a significant association between the diagnosis of MS and NAFLD (χ2 = 6.84, p = 0.01). As for the diagnostic components of MS, there was a positive and significant association between HDL-C (p = 0.05), waist circumference (p < 0.05) and hypertension (χ2 = 4.195, p = 0.041) with NAFLD. HOMA-IR (p < 0.001) also showed a positive association with liver disease. CONCLUSION: A positive and significant association between NAFLD and components of metabolic syndrome in class III obese individuals was observed, suggesting the need and importance of monitoring these components for NAFLD screening.

Energy Expenditure in Critically Ill Elderly Patients: Indirect Calorimetry vs Predictive Equations

Background: Predictive equations (PEs) are used for estimating resting energy expenditure (REE) when the measurements obtained from indirect calorimetry (IC) are not available. This study evaluated the degree of agreement and the accuracy between the REE measured by IC (REE-IC) and REE estimated by PE (REE-PE) in mechanically ventilated elderly patients admitted to the intensive care unit (ICU). Methods: REE-IC of 97 critically ill elderly patients was compared with REE-PE by 6 PEs: Harris and Benedict (HB) multiplied by the correction factor of 1.2; European Society for Clinical Nutrition and Metabolism (ESPEN) using the minimum (ESPENmi), average (ESPENme), and maximum (ESPENma) values; Mifflin–St Jeor; Ireton-Jones (IJ); Fredrix; and Lührmann. Degree of agreement between REE-PE and REE-IC was analyzed by the interclass correlation coefficient and the Bland-Altman test. The accuracy was calculated by the percentage of male and/or female patients whose REE-PE values differ by up to ±10% in relation to REE-IC. Results: For both sexes, there was no difference for average REE-IC in kcal/kg when the values obtained with REE-PE by corrected HB and ESPENme were compared. A high level of agreement was demonstrated by corrected HB for both sexes, with greater accuracy for women. The best accuracy in the male group was obtained with the IJ equation but with a low level of agreement. Conclusions: The effectiveness of PEs is limited for estimating REE of critically ill elderly patients. Nonetheless, HB multiplied by a correction factor of 1.2 can be used until a specific PE for this group of patients is developed.

Phase angle assessment in critically ill cancer patients: Relationship with the nutritional status, prognostic factors and death

Purpose: To evaluate the relationship between phase angle (PA) and nutritional status and the prognostic significance of PA in critically ill cancer patients. Methods: 31 patients that had been admitted to the intensive care unit (ICU) of a center on oncology were evaluated. Their PA was obtained from their bioelectrical impedance within 48 h of the ICU admission. The logistic regression analysis of Cox was used in order to identify the independent predictors of the outcomes. Results: Negative and significant correlations were observed between the PA and the following variables: the length of hospital ward stay, the length of ICU stay, the total time of hospital stay, the mechanical ventilation time, and the acute physiology and chronic health evaluation II (APACHE II) scores. A positive correlation was ascertained between the PA and albumin. PA was significantly associated with death. Patients with a PA ≤3.8° presented a significantly shorter survival time than those with a PA >3.8°. Conclusion: PA was a prognostic marker in this population, independently of previously established prognostic factors. PA can represent a clinically feasible approach for the initial identification of critically ill cancer patients who require an early and specialized nutritional intervention. HighlightsThe negatively correlated PA with length of hospital ward stayThe negatively correlated PA with length of ICU stay and APACHE II scoresThe negatively correlated PA with the total time of hospital stayA positive correlation was ascertained between the PA and albumin.PA was significantly associated with death.

Performance of Patient-Generated Subjective Global Assessment (PG-SGA) in Patients With Advanced Cancer in Palliative Care

Background: The purpose of this study was to evaluate the prognostic significance of the Patient-Generated Subjective Global Assessment (PG-SGA) in patients receiving palliative care for advanced cancer. Methods: The PG-SGA was used to assess nutrition status of 120 patients admitted to the Palliative Care Unit at the National Cancer Institute in Brazil. Results: According to the PG-SGA, 94.2% (n = 113) of the patients were evaluated as malnourished. The PG-SGA evaluated that xerostomia was the only symptom associated with a short survival (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.2–5.38; P = .014). Survival was found to be significantly higher in well-nourished (PG-SGA A) than malnourished (PG-SGA B [P = .021] or C [P = .013]) patients. Total PG-SGA score (hazard ratio [HR], 1.06; 95% CI, 1.001–1.09; P = .045) and Karnofsky Performance Status of 20%–30% (HR, 15.4; 95% CI, 1.63–92.9; P = .001) and 40%–50% (HR, 10.0; 95% CI, 1.22–64.9; P = .031) were found to be independent prognostic survival factors. Conclusion: The scored PG-SGA is an independent prognostic factor of survival and thus can be a useful tool for nutrition evaluation in palliative care.

Vitamin A metabolic aspects and alcoholic liver disease

The liver is a strategic organ in the metabolism of macro and micronutrients; when its functioning is compromised, it may cause some change in the nutritional status of vitamin A. The purpose of this article is to review scientific evidence in literature on the liver metabolism of vitamin A, the role of ethanol and retinol interactions on hepatic morphology, besides the alterations in the metabolism of this vitamin in alcoholic liver disease. Data were collected from Medline database. The liver is the main organ responsible for the storage, metabolism and distribution of vitamin A to peripheral tissues. This organ uses retinol for its normal functioning such as cell proliferation and differentiation. This way, vitamin A deficiency seems to alter liver morphology. Patients with alcoholic liver disease have been found to have low hepatic levels of retinol in all stages of their disease. In alcoholic liver disease, vitamin A deficiency may result from decreased ingestion or absorption, reduction in retinoic acid synthesis or increased degradation. Long-term alcohol intake results in reduced levels of retinoic acid, which may promote the development of liver tumor. So, in chronic alcoholic subjects, vitamin A status needs to be closely monitored to avoid its deficiency and clinical effects, however its supplementation must be done with caution since the usual dose may be toxic for those who consume ethanol.

Cross-cultural adaptation and content validation into Portuguese of the Subjective Global Nutritional Assessment for pediatric patients hospitalized with cancer

1 Instituto Nacional de Câncer José Alencar Gomes da Silva, Hospital do Câncer I, Serviço de Nutrição e Dietética. Rio de Janeiro, RJ, Brasil. 2 Instituto Nacional de Câncer José Alencar Gomes da Silva, Hospital do Câncer I, Divisão de Apoio Técnico. Rio de Janeiro, RJ, Brasil. 3 Universidade Federal do Rio de Janeiro, Instituto de Nutrição Josué de Castro, Departamento de Nutrição e Dietética. Av. Carlos Chagas Filho, 373, Bloco J, Sala 7, Ilha do Fundão, 21941-590, Rio de Janeiro, RJ, Brasil. Correspondência para/Correspondence to: DCA SARAIVA. E-mail: .