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Alloveda Liver Update: Nutritional deficiencies in Cholestasis

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eMediNexus    26 January 2021

The liver plays a major role in regulation of various aspects of lipid metabolism. Its primary function involves production of bile, and its constituents are essential for effective intestinal fat absorption. In addition, biliary secretion of cholesterol and phospholipids from the liver into the intestine is important pathway implicated in body lipid homeostasis. Besides, liver is an essential source of plasma lipoproteins as it synthesizes apoproteins such as apo A-I, apo B, apo E, which can control several complex metabolic interconversions between lipoprotein and its constituents such as cholesterol, triglycerides, and phospholipids. It also synthesizes enzymes such as LCAT, CETP, PLTP, LPL that are employed in lipoprotein metabolism and acts as a chief site of clearance of circulating lipoproteins, which are further catabolized in the hepatocytes. Therefore, it can be postulated that disturbances in bile formation occurring in cholestatic liver disease have a significant effect on various aspects of lipid metabolism in the body.

 

Chronic cholestasis is usually observed to be associated with multiple nutritional deficiencies because of insufficient dietary intake, maldigestion, malabsorption and/or defective metabolism of nutrients. Moreover, requirements of energy and/or specific nutrients get increased during cholestasis as the recommended caloric intake for these patients is 130% of recommended daily allowance, which is fulfilled by dietary supplementation with glucose polymers and/or medium-chain triglycerides (MCT) oil enriched with essential fatty acid-rich oils. Usually, enteral route is preferred for patients with cholestasis, however, in severe chronic malabsorption, nasogastric and nocturnal feedings can be required.

Besides, fat-soluble vitamin deficiency is commonly encountered in cholestatic children, which warrants the needs of adequate and rapid treatment. A regimen of oral 25-OHD, at a dose of 2–4 μg/kg/d in children and 50–100 μg in adults is recommended for the treatment of vitamin D deficiency. Additionally, vitamin K supplementation at dose of 2.5–5 mg, 2–7 times a week is recommended as prophylaxis for all children with chronic cholestasis. Standard oral forms of vitamin E (α-tocopherol, α-tocopheryl acetate, α-tocopheryl succinate) are recommended at doses starting from 10–25 IU/kg/d increasing to 100–200 IU/kg/d in cases pf vitamin E deficiency. However, in cases where normalization of plasma vitamin E levels is not attained, a water-soluble form of vitamin E known as d-α-tocopheryl polyethylene glycol-1000 succinate (TPGS) can cause significant enhancement in the vitamin E status in cholestatic patients. Moreover, 10,000 IU dosage of vitamin A along with TPGS is recommended dosage in patients with chronic cholestasis. Nevertheless, it is important to ascertain that plasma vitamin levels should be carefully observed to avoid excessive serum levels and toxicity, regardless of the form of vitamin supplemented.

Source: Werner A, Kuipers F, Verkade HJ. Fat Absorption and Lipid Metabolism in Cholestasis. Available at: https://www.ncbi.nlm.nih.gov/books/NBK6420/. Accessed on: 05-01-2021.

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