Hepatobiliary nutrition: history and future
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The liver is a master metabolic gland; consequently, liver disease commonly results in significant malnutrition. Complex metabolic derangements always accompany liver failure, often reflect the magnitude of hepatic insufficiency, and are characterized by accentuated catabolism. Nutritional assessment is problematic in these patients, because many of the usual indicators of nutritional status are altered directly by the hepatic pathophysiology rather than, or in addition to, preexisting or subsequent secondary malnutrition. The objective of nutritional support in patients with liver failure is to provide adequate nutrients to ensure the availability of specific substrates for energy and protein synthesis and for normal hepatocyte survival and function, without inducing or accentuating encephalopathy or otherwise compounding hepatic insufficiency. In the near future, guidelines must be developed for the specific nutritional support of patients with fulminant hepatic failure, cholestatic liver disease, steatosis, and cirrhosis. Currently, work is underway to develop an artificial liver for patients awaiting transplantation; to use genetic engineering technology to provide an alternative source of hepatic tissue; and to test the utility of various intermediary metabolites for hepatobiliary nutrition support. No ideal regimen for nutritional support of all forms of liver failure exists, and this also represents a significant challenge for future basic and clinical investigations. However, it is mandatory to attempt to maintain optimal nutrition in patients with severe liver failure if morbidity and mortality are to be reduced and survival is to be maximized.
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