Lecture: micronutrient deficiencies in the liver patient

This lecture focused on the micronutrient deficiencies in the liver patient, and in particular, the alcoholic liver patient.  There are several reasons for these patients being malnourished, including poor PO intake, poor compliance with specific food and vitamin directives, malabsorption (bacterial overgrowth, edematous bowel from ascites), and a gernalized catabolic state of health.

Vitamin A is the one that is typically associated with hypervitaminosis; caution should be made for those who are consuming particularly large quantities of it through food or drink, as it can cause a severe hepatitis.  The B complex vitamins are frequently deficient.  Remember thiamine should be given before glucose in the alcoholic patient; niacin deficiency causes pellagra and the 4 D’s.  Cobalamin deficiency can cause memory loss, confusion or depression.  Vitamin C deficiency can cause wound-healing impairment.  Recall that vitamin C supplements should generally be avoided in patients with iron overload, as it increases the gut’s rate of iron absorption from the duodenum.

Speaking of iron, there are no official recommendations to limit iron-laden foods for those with iron overload.  Iron deficiency is of course common, and the specifics were not addressed in this lecture.  Vitamin D deficiency is implicated in many systemic diseases, and liver disease is no exception.  Along with metabolic bone disease, it is also implicated in pathways of fibrosis as well as steatosis.  A good rule of thumb is that deficient patients should be given 2,500 units of vitamin D and 2,500 units of calcium as supplements (easy to remember).  We should be measuring the 25-OH serum levels of vitamin D, not the 1-25-OH levels.

Other micronutrients discussed included zinc, which is commonly associated with alterations in taste and smell.  Magnesium is commonly associated with muscle cramping (and may be associated with renal wasting if patient is on diuretics).  Either of these elements can have levels checked and supplementation prescribed.

Vitamin E is sometimes used to treat NASH.  In high quantities of supplementation (ie. 800 IU/day) it may be associated with increased adverse events (?cardiovascular) so be sure you are not prescribing high doses.  If the indication is NASH, the appropriate candidate will have a high NAS score on liver biopsy.

In summary, the alcoholic or cirrhotic patient is bound to be malnourished and have many vitamin and mineral deficiencies.  The more familiar you are with each’s clinical presentation, the quicker you’ll be in making an appropriate diagnosis and supplementing the deficiency.

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