[Nutritional therapy in liver transplantation]

Antioxidant Potential and Modulatory Effects of Restructured Lipids from the Amazonian Palms on Liver Cells

Enzymatic interesterification is used to manipulate oil and fat in order to obtain improved restructured lipids with desired technological properties. However, with raw materials containing significant amounts of bioactive compounds, the influence of this enzymatic process on the bioactivity of the final product is still not clear. Thus, the aim of this study is to evaluate the antioxidant potential and modulatory effects of two raw materials from the Amazonian area, buriti oil and murumuru fat, before and after lipase interesterification, on human hepatoma cells (HepG2). The results indicate that minor bioactive compounds naturally found in the raw materials and their antioxidant capacity are preserved after enzymatic interesterification, and that the restructured lipids modulate HepG2 endogenous antioxidant enzyme.

DIETARY MANAGEMENT FOR DYSLIPIDEMIA IN LIVER TRANSPLANT RECIPIENTS

Background

Dyslipidemia occurs in approximately 70% of all liver transplant (LT) recipients, and no prior control studies have demonstrated any dietary intervention to change it.

Aim

To analyze the effects of a dietary intervention on the lipid profile of dyslipidemic LT recipients.

Methods

All LT recipients with dyslipidemia on clinical follow-up were enrolled. Anthropometric evaluation, food history, body composition (bioimpedance) and assessment of basal metabolism through indirect calorimetry were performed. Patients met with a dietitian and an individualized diet based on estimate of basal metabolism and consisting of 25% of the total energy value in total fat and <200 mg/day of cholesterol was prescribed. Total cholesterol (TC), HDL-cholesterol (HDL), LDL-cholesterol (LDL), triglycerides (TG) and anthropometric measures were measured at baseline and six months after intervention.

Results

Fifty-thee out of 56 patients concluded follow-up; age was 59±10 years; 29 were men (51.8%). The analysis pre- and post-intervention were, respectively: TC 238.9±30 and 165.1±35, p<0.001; LDL 154±33 and 90±29, p<0.001; and TG 168 (IQR=51-200) and 137 (IQR=94-177), p=<0.001. They were all modified at six months following intervention. At baseline, none of the patients had normal TC, and only 12 (22.7%) had optimal/near optimal LDL. Following dietary intervention, 45 patients (84.9%) reached normal TC and 50 (94.4%) had optimal/near optimal LDL. HDL and anthropometric measures were not modified.

Conclusions

Dietary counseling with prescription of individualized diet based on estimate of basal metabolism through indirect calorimetry was able to manage dyslipidemia in most LT recipients; so, all dyslipidemic LT recipients must be enrolled on a dietary program.

ESTIMATING BASAL ENERGY EXPENDITURE IN LIVER TRANSPLANT RECIPIENTS: THE VALUE OF THE HARRIS-BENEDICT EQUATION

Background:

Reliable measurement of basal energy expenditure (BEE) in liver transplant (LT) recipients is necessary for adapting energy requirements, improving nutritional status and preventing weight gain. Indirect calorimetry (IC) is the gold standard for measuring BEE. However, BEE may be estimated through alternative methods, including electrical bioimpedance (BI), Harris-Benedict Equation (HBE), and Mifflin-St. Jeor Equation (MSJ) that carry easier applicability and lower cost.

Aim:

To determine which of the three alternative methods for BEE estimation (HBE, BI and MSJ) would provide most reliable BEE estimation in LT recipients.

Methods:

Prospective cross-sectional study including dyslipidemic LT recipients in follow-up at a 735-bed tertiary referral university hospital. Comparisons of BEE measured through IC to BEE estimated through each of the three alternative methods (HBE, BI and MSJ) were performed using Bland-Altman method and Wilcoxon Rank Sum test.

Results:

Forty-five patients were included, aged 58±10 years. BEE measured using IC was 1664±319 kcal for males, and 1409±221 kcal for females. Average difference between BEE measured by IC (1534±300 kcal) and BI (1584±377 kcal) was +50 kcal (p=0.0384). Average difference between the BEE measured using IC (1534±300 kcal) and MSJ (1479.6±375 kcal) was -55 kcal (p=0.16). Average difference between BEE values measured by IC (1534±300 kcal) and HBE (1521±283 kcal) was -13 kcal (p=0.326). Difference between BEE estimated through IC and HBE was less than 100 kcal for 39 of all 43patients.

Conclusions:

Among the three alternative methods, HBE was the most reliable for estimating BEE in LT recipients.

Liver transplantation: evidence for nursing care

Evidence-based practice is the adopted theoretical and methodological framework and the integrative literature review was the research method used for this study. This study aimed to search and evaluate evidence available in literature about scientific knowledge on nursing care to adult patients submitted to liver transplantation during the perioperative period. Lilacs, Medline and Cinahl were used for the search, which resulted in a sample of 20 scientific papers. The results evidenced publications on nursing care to prepare the patient, prevent injuries, on the importance of a documentation system, prevention and early detection of complications, as well as education on immunosuppressive therapeutics, patient education and nursing activities in the pre, intra and postoperative periods, and the nurses' role in providing nutritional and emotional support to patients and family members.

[Nutritional evaluation of the cirrhotic patient: an objective, subjective or multicompartmental approach?]

BACKGROUND

Malnutrition due to liver disease is common and its assessment is difficult. The parameters of nutritional evaluation often used in clinical practice have limited use in cirrhotic patients. Many of the clinical signs of malnutrition are the result of the underlying hepatic disease which tends to confound and alter the nutritional diagnosis.

AIM

To present a brief review of the different methods of nutritional evaluation together with their limitations and uses in cirrhotic patients.

CONCLUSION

The multicompartmental approach for four compartments was shown to be considerably sensitive in the detection of malnutrition. However the ample use of this method is impaired due to technical difficulties and high costs. The handgrip strength appears to be a simple, cheap and effective alternative to detected malnutrition and risk of malnutrition in these patients. Is the most sensitive method and is able to predict a significant incidence of major complications in undernourished cirrhotic patients.

Intensive Care Complications in Liver and Multivisceral Transplantation

The complications concerning liver and intestinal transplant surgery have relevance for the field of intensive care because they share some characteristics with those following complex long-term surgery. Thus, in this article we shall try to describe complications that are specific to liver and multivisceral transplants. A review of the existing literature on this topic reveals a large number of studies dedicated to early as well as late surgical complications, and immunosuppressive treatment, while there are far fewer contributions describing complications exclusively concerning intensive care. We shall thus attempt to focus on certain aspects where, besides the literature data, we have personal experience. In particular we want to underline the implications of failure in the functional recovery of the graft; alterations in water, electrolyte, and glycemic balance; as well as neurological, respiratory, renal, nutritional, and infective complications.

[Nutritional assessment in patients with cirrhosis: the use of indirect calorimetry]

BACKGROUND

Malnutrition is frequent in cirrhotic patients, and its assessment is difficult. Functional assessment through a dynamometer is a simple method and could minimize these drawbacks. Harris-Benedict prediction formulae estimates the resting energy expenditure but has not been validated for this population. One alternative is the use of indirect calorimetry.

AIM

To assess nutritional status in cirrhotic patients and estimates the resting energy expenditure through indirect calorimetry and compares it to Harris-Benedict.

PATIENTS AND METHODS

Thirty four adult hepatitis C cirrhotic outpatients were studied, classified by Child-Pugh and model of end-stage liver disease score. The resting energy expenditure was predicted through Harris-Benedict and measured by indirect calorimetry. Nutritional assessment was done through anthropometry, subjective global assessment, hand-grip strength and a 3-day recall.

RESULTS

Fifteen (44.2%) were Child-Pug A, 12 (35.3%) B and 7 (20.6%) C, and 33 (97.1%) had model of end-stage liver disease scores less than 20. The resting energy expenditure predicted was higher than the measured (Harris-Benedict 1404.5 +/- 150.3 kcal; indirect calorimetry 1059.9 +/- 309.6 kcal). The prevalence of malnutrition varied between methods (body mass index, muscle arm circumference, subjective global assessment, triceps skinfold thickness and hand-grip strength: 0; 5.9; 17.6; 35.3 and 79.4%, accordingly). Calories and proteins intake were 80% and 85% of recommended amounts and there was inadequate intake of calcium, magnesium, iron and zinc.

CONCLUSION

Malnutrition was frequent and hand-grip strength seemed to be the most sensitive method for its diagnosis. Calories and protein intakes were inadequate. Considering that the predicted resting energy expenditure was higher than the measured one and the need to offer higher caloric intake, the use of the predicting equation may replace indirect calorimetry.

O uso de nutrição enteral precoce pós-transplante hepático adulto

RACIONAL: O transplante hepático é o tratamento de escolha para várias doenças hepáticas terminais. A desnutrição nesta população é freqüente. O uso de nutrição enteral precoce não é rotina nos grupos de transplante. OBJETIVO: Relatar a experiência do uso de nutrição enteral precoce em indivíduos transplantados hepáticos e avaliar sua segurança. PACIENTES/MÉTODOS: Foram estudados 35 adultos submetidos a transplante hepático. A avaliação do estado nutricional pré-transplante hepático foi realizada pela avaliação nutricional subjetiva global e força do aperto da mão não-dominante, aferida pela dinamometria. A dieta enteral foi iniciada em até 12 horas. A via oral foi iniciada assim que houvesse ruídos hidroaéreos. RESULTADOS: A média de idade dos indivíduos avaliados foi de 45,5 anos (± 8,93). De acordo com a avaliação nutricional subjetiva global, a prevalência de desnutrição pré-transplante foi de 77,1% e pela força do aperto da mão não-dominante de 100%. A nutrição enteral precoce foi iniciada em até 12 horas, moda de 10,9 horas e mantida exclusivamente por período médio de 2,6 dias (± 2,2). Via oral exclusiva foi obtida no período médio de 9,5 dias (± 9,7). A nutrição enteral precoce proveu o aporte calórico estimado em 97% dos casos. Intolerância à dieta enteral ocorreu em cinco indivíduos (14,2%), sendo que em quatro foi reinstituída com sucesso após intervalo de 12 horas. A prevalência de infecção respiratória foi de 28,6%. Em apenas dois pacientes (5,7%) houve broncopneumonia com aspecto aspirativo ao estudo radiológico do tórax. CONCLUSÕES: A nutrição enteral precoce foi um método eficaz na provisão de calorias e seguro em sua aplicação a pacientes transplantados hepáticos.

Prevalence of malnutrition in liver transplant candidates

OBJECTIVE

To determine the prevalence of malnutrition among liver transplant (LT) candidates.

MATERIALS AND METHODS

A prospective study evaluated 219 adult LT candidates including 141 men and 78 women. Cholestatic disease was present in 21 (Child: A = 1, B = 11, and C = 9) and noncholestatic disease in 198 (Child: A = 12, B = 93, and C = 93. The mean age was respectively 45.6 and 46.5 years. Anthropometric and biochemical assessments were performed for statistical analysis using Student t test (P <.05).

RESULTS

In the noncholestatic group, 41.5% were obese according to keep a body mass index (BMI); 61.6% were depleted according to adequacy of tricipital skin fold (%TSF); and 71.1% were above normal levels for generalized adipose reserve (%F). In terms of adequacy of mid-upper arm muscle circumference (%MMC), 58% were depleted and 50.5% were depleted for the current body weight/usual body weight (%CBW/UBW). Otherwise 52.2% of current body weight/ideal body weight (%CBW/IBW) values were above normal. Serum albumin was below normal in 64.9% of cases. In the cholestatic group 62% were normal for BMI; 66.7% were depleted for %TSF; 77.8% were above normal for %F. As to %MMC, 47.6% were depleted and 47.6% were depleted for %CBW/UBW. Otherwise 47.6% were above normal weight for %CBW/IBW. Serum albumin was below normal in 53.9% and %MMC values showed statistically significant differences (P =.02) when compared with Child B and C in the noncholestatic group, as well as %F (P =.01) and serum albumin (P =.0002) in the cholestatic and noncholestatic groups. Serum albumin values also showed statistically significant differences (P =.0004) when noncholestatic Child B and C patients were compared.

CONCLUSION

Patients with cholestatic disease were more affected by calorie depletion compared to noncholestatic patients who were more affected by protein depletion.