Malnutrition and liver disease in a developing country

Undernutrition and Intestinal Infections in Children: A Narrative Review

Undernutrition affects thousands of children under five years old worldwide, and various factors are related to its onset, among which we highlight enteric infections and gastrointestinal barrier dysfunction. The cycle of intestinal infections and undernutrition has long-term consequences, such as cognitive deficits, poor growth, and metabolic diseases in adulthood. This review explores factors linked to childhood undernutrition, focusing on intestinal infections and markers of intestinal permeability that affect child development. This narrative review was conducted using Medline/PubMed, Web of Science, and Scopus, from July 2024 to March 2025. Studies involving children under five years old and addressing undernutrition, intestinal infections, or intestinal permeability markers were included. Exclusion criteria comprised studies without therapeutic focus, and books, case reports, or academic theses. No language restrictions were applied, and registration on global platforms was not required. Overall, the studies reported a close relationship between enteric pathogens, diarrheal and non-diarrheal stools, and undernutrition. Among the pathogens most frequently found in the feces of malnourished children were Shigella, enterotoxigenic Escherichia coli, enteroaggregative E. coli (EAEC), and Cryptosporidium. The studies also showed the relationship between gastrointestinal barrier function and undernutrition, with the deterioration of nutrient absorption and, consequently, repercussions on development, linear growth, and weight in children. Although the studies analyzed had different designs and heterogeneity in the age range of the studied children, it was possible to observe the relationship between the infection/undernutrition cycle. Future studies should optimize personalized nutrient-based therapies, assess long-term effects on gut health and growth, and explore the gut microbiome's role in enteric infection susceptibility and undernutrition.

Exposure to airborne particulate matter and undernutrition in young rats: An in-depth histopathological and biochemical study on lung and excretory organs

Environmental stressors, such as air particulate matter (PM) and nutrient deficiencies, can significantly impact crucial organs involved in detoxifying xenobiotics, including lungs, liver, and kidneys, especially in vulnerable populations like children. This study investigated the effect of 4-week exposure to Residual Oil Fly Ash (ROFA) on these organs in young rats under growth-restricted nutrition (NGR). We assessed histological, histomorphometric and biochemical parameters. ROFA exposure induced histological changes and inflammation in all three organs when compared to control (C) animals. Specifically, in lungs ROFA caused a significant reduction in alveolar airspace (C: 55.8 ± 1.8% vs. ROFA: 38.7 ± 3.0%, p < 0.01) and alveolar number along with changes in alveolar size distribution, and disruption of the smooth muscle layer which may impaired respiratory function. In the liver, ROFA increased binucleated cells, macro and microvesicles and both AST and ALT serum biomarkers (AST: C = 77.7 ± 1.3 vs. ROFA = 81.6 ± 1.3, p < 0.05; ALT: C = 44.5 ± 0.9 vs. ROFA = 49.4 ± 1.3, p < 0.05). In the kidneys, a reduced Bowman's space (C: 2.15 ± 0.2 mm2 vs. ROFA: 1.74 ± 0.2 mm2, p < 0.05) was observed, indicative of glomerular filtration failure. NGR alone reduced Bowman's space (C: 2.15 ± 0.2 mm2 vs. NGR: 1.06 ± 0.1 mm2, p < 0.001). In lung and liver NGR showed higher levels of proinflammatory cytokine IL-6 (p < 0.01 and p < 0.001, respectively) when compared to C. In conclusion, both stressors negatively affected lung and excretory organs in young rats, with nutritional status further modulating the physiological response to ROFA. These findings highlight the compounded risks posed by environmental pollutants and poor nutrition in vulnerable populations.

Dysgeusia in MASLD-related advanced chronic liver disease (ACLD): a silent driver towards the "Bermuda" triangle of malnutrition-sarcopenia-frailty severely affecting prognosis

BACKGROUND

Dysgeusia is a distortion of the sense of taste whose prevalence and relationship with nutritional status in Metabolic dysfunction-associated Steatotic Liver Disease (MASLD)-related advanced chronic liver disease (ACLD) have never been systematically explored.

METHODS

200 MASLD patients [60 ≤ F3 fibrosis, 70 compensated ACLD (cACLD), and 70 decompensated (dACLD)] were enrolled. At baseline, the Child-Pugh (CP) score was determined. Dietary habits, body composition, and frailty were evaluated. The European Working Group (EWGSOP2) criteria defined sarcopenia. Dysgeusia was assessed by the Dysgeusia-Total-Score (DTS). A visual analog scale identified appetite impairment (VASAI). During a 6-month follow-up, liver-related decompensation events (LRDEs) were recorded.

RESULTS

The prevalence of dysgeusia increased with the liver disease progression, appearing significantly higher in ACLD compared with ≤ F3 (65.7% vs 5%, p:0.003), as well as in dACLD compared to cACLD patients (58.5 vs 7.1% p < 0.0001). On 41 dACLD patients presenting dysgeusia, 37 (90.2%) showed a significant impairment of appetite levels. In dACLD, the CP score was positively correlated with both DTS (R:0.742) and VASAI (R:0.704), as well as DTS was directly correlated with VASAI (R:0.765) (all p < 0.0001). Compared with dACLD patients without dysgeusia, dysgeusia-affected dACLD patients presented a lower daily protein intake (g/kg/die) (1.55 ± 0.192 vs 1.34 ± 0.15, p < 0.0001). Sarcopenia (70.7 vs 41.3%) and frailty (69.29 vs 37.9%) were significantly more prevalent in dysgeusia-affected dACLD individuals (both p < 0.0001). These patients showed a higher risk of LRDEs occurrence during the follow-up [HR:2.205; C.I. 95%:1.186-4.099; p:0.01]. Logistic regression analysis revealed dysgeusia (aOR: 3.32), appetite impairment (aOR:1.32), sarcopenia (aOR: 3.75), and frailty (aOR:3.03) significantly associated with this outcome (all p < 0.0001).

CONCLUSIONS

Dysgeusia appears predominant in MASLD-dACLD and, via appetite impairment, in a close relationship with malnutrition, sarcopenia, and frailty, negatively influencing patients' outcomes.

Demographic, clinical and psychological predictors of malnutrition among people with liver cancer

PURPOSE

This study aimed to explore the nutritional status and examine the demographic, clinical, nutritional, and psychosocial characteristics associated with malnutrition among people with liver cancer.

METHODS

A descriptive cross-sectional design was used. Data were collected from a convenience sample of 162 liver cancer outpatients at a tertiary university hospital. Nutritional status was evaluated using the Patient-Generated Subjective Global Assessment (PG-SGA). Self-administered structured questionnaires were administered, and medical records were reviewed for demographic, clinical, nutritional, and psychosocial characteristics.

RESULTS

Based on PG-SGA scores, 27 patients (16.7%) were classified into the malnutrition group. The stages of liver cancer, chemotherapy, physical and psychological symptom distress, global distress index, levels of alpha-fetoprotein and protein induced by vitamin K absence or antagonists, body mass index, appetite, hemoglobin and albumin levels, and depression were statistically significantly associated with malnutrition. Logistic regression model revealed that physical symptom distress, liver cancer stage, depression, and body mass index influenced statistically significantly malnutrition.

CONCLUSIONS

In this study, clinical, nutritional, and psychosocial characteristics predicted malnutrition among people with liver cancer. Nurses should consider these characteristics when evaluating the nutritional status of people with liver cancer.

Prognostic Nutritional Index Correlates with Liver Function and Prognosis in Chronic Liver Disease Patients

The Prognostic Nutritional Index (PNI) is widely recognized as a screening tool for nutrition. We retrospectively examined the impact of PNI in patients with chronic liver disease (CLD, n = 319, median age = 71 years, 153 hepatocellular carcinoma (HCC) patients) as an observational study. Factors associated with PNI < 40 were also examined. The PNI correlated well with the albumin-bilirubin (ALBI) score and ALBI grade. The 1-year cumulative overall survival rates in patients with PNI ≥ 40 (n = 225) and PNI < 40 (n = 94) were 93.2% and 65.5%, respectively (p < 0.0001). In patients with (p < 0.0001) and without (p < 0.0001) HCC, similar tendencies were found. In the multivariate analysis, hemoglobin (p = 0.00178), the presence of HCC (p = 0.0426), and ALBI score (p < 0.0001) were independent factors linked to PNI < 40. Receiver operating characteristic (ROC) curve analysis based on survival for the PNI yielded an area under the ROC curve of 0.79, with sensitivity of 0.80, specificity of 0.70, and an optimal cutoff point of 42.35. In conclusion, PNI can be a predictor of nutritional status in CLD patients. A PNI of <40 can be useful in predicting the prognosis of patients with CLD.

Association between macronutrients intake and liver dysfunction among tuberculosis patients in rural China

BACKGROUND AND OBJECTIVES

Macronutrients play a vital role in liver dysfunction and affect tuberculosis treatment and prognosis. However, macronutrients intake was inadequate for most tuberculosis patients. This study aimed to clarify the associations between macronutrients intake or energy percentages and liver dys-function in tuberculosis patients.

METHODS AND STUDY DESIGN

In this cross-sectional study, 2581 active tu-berculosis patients aged ≥18 years were included from local tuberculosis clinics in Linyi, China. Macronutrients intake and energy percentages were assessed by 24-hour dietary recalls. The concentration of alanine transferase (ALT) or aspartate transaminase (AST) greater than 40 U/L was defined as liver dysfunction. A restricted cubic spline (RCS) was applied to determine the dose-response relationships.

RESULTS

Liver dysfunction was assessed for 14.6% (377 patients) of tuberculosis patients. Higher protein (Q2-Q4 in model 1 and 2) or fat intake and fat-to-energy percentages and lower carbohydrate-to-energy percentages (Q4 in model 1) were associated with a decreased incidence of liver dysfunction (p-trend < 0.05). Among those who were male, normal BMI, or consumed energy <1636 kcal/d, inverse associations between protein or fat intake and the risks of liver dysfunction in models were suggested (p-trend < 0.05). Moreover, J-shaped curves in RCS were evident in liver dysfunction tuberculosis patients with protein or fat intake (p-nonlinearity < 0.05). Conclu-sions: Significant linear associations between macronutrients intake or energy percentages and liver dysfunction prevalence were found only in male, normal BMI, or less energy intake patients. The shapes of liver dysfunction-morbidity differed significantly by macronutrients intake or energy percentage.

Sarcopenia in chronic viral hepatitis: From concept to clinical relevance

Although the frequency of metabolic risk factors for cirrhosis and hepatocellular carcinoma (HCC) is increasing, chronic hepatitis B (CHB) and chronic hepatitis C (CHC) remain the most relevant risk factors for advanced liver disease worldwide. In addition to liver damage, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are associated with a myriad of extrahepatic manifestations including mixed cryoglobulinaemia, lymphoproliferative disorders, renal disease, insulin resistance, type 2 diabetes, sicca syndrome, rheumatoid arthritis-like polyarthritis, and autoantibody production. Recently, the list has grown to include sarcopenia. Loss of muscle mass or muscle function is a critical feature of malnutrition in cirrhotic patients and has been found in approximately 23.0%-60.0% of patients with advanced liver disease. Nonetheless, among published studies, there is significant heterogeneity in the aetiologies of hepatic diseases and measurement methods used to determine sarcopenia. In particular, the interaction between sarcopenia, CHB and CHC has not been completely clarified in a real-world setting. Sarcopenia can result from a complex and multifaceted virus-host-environment interplay in individuals chronically infected with HBV or HCV. Thus, in the present review, we provide an overview of the concept, prevalence, clinical relevance, and potential mechanisms of sarcopenia in patients with chronic viral hepatitis, with an emphasis on clinical outcomes, which have been associated with skeletal muscle loss in these patients. A comprehensive overview of sarcopenia in individuals chronically infected with HBV or HCV, independent of the stage of the liver disease, will reinforce the necessity of an integrated medical/nutritional/physical education approach in the daily clinical care of patients with CHB and CHC.

The relationship between co-exposure to multiple heavy metals and liver damage

BACKGROUND

The impact of heavy metal exposure on human health has attracted widespread attention of researchers, and the impact of heavy metal exposure on liver function has also been confirmed, however, more attention is paid to the impact of single or two heavy metal exposures, and most epidemiological studies focus on heavy metal pollution areas. In this study, rural residents in non-heavy metal-contaminated areas in Northwest China were selected as the research objects to explore the comprehensive effects of co-exposure to multiple heavy metals on the liver, which can provide certain reference and support for related research.

OBJECTIVES

This study used a Bayesian nuclear machine model (BKMR) to evaluate the relationship between exposure to heavy metal mixtures and indicators of liver function in a population in rural Northwest China.

RESULTS

Exposure to higher concentrations of metal mixtures was positively correlated with total bilirubin, direct bilirubin, and aspartate aminotransferase, and negatively correlated with alanine aminotransferase, with Pb contributing the most to indicators of liver function. We also observed a possible interaction of Cd with other heavy metals in the effect of heavy metal mixtures on DB levels.

CONCLUSIONS

Concurrent exposure to higher concentrations of heavy metal mixtures (Cr, Co, Cd, and Pb) in rural China was associated with indicators representing poor liver function, of which the effect of lead on liver function should be focused. More prospective epidemiological studies and animal experiments need to be carried out to determine this relationship and possible mechanism.

Prognosis of systemic inflammation at an early stage of cirrhosis using the monocyte-to-lymphocyte ratio during malnutrition risk screening: a prospective cohort study

OBJECTIVE

To determine whether the monocyte-to-lymphocyte ratio (MLR), as a systemic inflammation index, predicts malnutrition risk during the early stages of cirrhosis.

METHODS

We conducted a single-center prospective cohort study, enrolling patients from June 2016 to September 2020. The patients underwent malnutrition risk assessments upon admission. The patients were classified into five clinical stages according to portal hypertension. The malnutrition risk was scored using the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) and validated by the Nutritional Risk Screening 2002 (NRS-2002) or Liver Disease Undernutrition Screening Tool (LDUST). Routine clinical laboratory measurements were performed to calculate the MLR, Child-Turcotte-Pugh (CTP) class, and model for end-stage liver disease (MELD) score. The patients were followed up for 2 years.

RESULTS

Among the 154 patients with cirrhosis, 60 had compensated cirrhosis and 94 had decompensated cirrhosis. The optimal cutoff value of the MLR, >0.4, was effective in predicting malnutrition related to death or liver transplantation. Those with a high malnutrition risk defined by the NRS-2002 or RFH-NPT had a higher MLR than those with a low malnutrition risk. For patients with class A CTP cirrhosis or a MELD score of <10, an MLR cutoff of <0.4 significantly distinguished more patients with a low malnutrition risk than those with a high malnutrition risk. Both the RFH-NPT score and MLR increased significantly across the decompensated cirrhosis substages. Interestingly, the MLR exhibited a positive correlation with the RFH-NPT score until varices appeared, but the correlation was the highest at the substage of a history of variceal bleeding (r = 0.714, P = 0.009). Multivariable analysis demonstrated that an MLR of >0.4 was an independent factor for malnutrition risk by screening with the RFH-NPT, and this was confirmed using the LDUST and NRS-2002.

CONCLUSION

Immune-related inflammatory dysfunction predicts malnutrition risk during the early stages of cirrhosis.

Mechanism for development of malnutrition in primary biliary cholangitis

Primary biliary cholangitis (PBC) is a chronic cholestatic liver disease that is associated with impaired biliary excretion processes. Along with the development of cholestasis, there is a deficient flow of bile acids into the intestinal lumen causing malnutrition (MN) that is manifested in deficiencies of both macro- and micronutrients. The mechanism for development of trophological insufficiency is multifactorial. However, the trigger of MN in PBC is impaired enterohepatic circulation of bile acids. The ingress of bile acids with a detergent effect into the general bloodstream, followed by elimination via the kidneys and skin, triggers a cascade of metabolic disturbances, which leads to the gradual development and progression of calorie MN. The latter gradually transforms into protein-calorie MN (PСM) (as marasmus) due to the insufficient entry of bile acids into the duodenum, which is accompanied by a decrease in the emulsification, hydrolysis, and absorption of fats and fat-soluble vitamins, as well as disturbance of intestinal motility and bacterial overgrowth. Fat-soluble vitamin deficiencies complement PСM with vitamin and mineral MN. The development of hepatocellular failure enhances the progression of PСM due to the impaired protein synthetic function of hepatocytes in the advanced stage of PBC, which results in deficiency of not only the somatic but also the visceral pool of proteins. A mixed PСM form of marasmus and kwashiorkor develops. Early recognition of energy, protein, micronutrient, and macronutrient deficiencies is of great importance because timely nutritional support can improve liver function and quality of life in patients with PBC. In this case, it is important to know what type (energy, protein-calorie, vitamin, and vitamin-mineral) and form (marasmus, marasmus-kwashiorkor) of MN is present in the patient and how it is associated with the stage of the disease. Therefore, it is recommended to screen all patients with PBC for MN, from the early asymptomatic stage of the disease in order to identify and avoid preventable complications, such as fatigue, malaise, performance decrement, sarcopenia, osteoporosis, and hepatic encephalopathy, which will be able to provide appropriate nutritional support for correction of the trophological status.