Protein energy malnutrition in severe alcoholic hepatitis: diagnosis and response to treatment. The VA Cooperative Study Group #275.
BACKGROUND
Active nutrition therapy and the anabolic steroid oxandrolone (OX), in selected patients with severe alcoholic hepatitis, significantly improved liver status and survival. We report here on the changes in their nutritional parameters.


METHODS
Protein energy malnutrition (PEM) was evaluated and expressed as percent of low normal in 271 patients initially, at 1 month and at 3 months. Active therapy consisted of OX plus a high caloric food supplement vs a matching placebo and a low calorie supplement.


RESULTS
PEM was present in every patient; mean PEM score 60% of low normal. Most of the parameters improved significantly from baseline on standard care; the largest improvement seen in visceral proteins, the smallest in fat stores (skinfold thickness). Total PEM score significantly correlated with 6 month mortality (p = .0012). Using logistic regression analysis, creatinine height index, hand grip strength and total peripheral blood lymphocytes were the best risk factors for survival. When CD lymphocyte subsets replaced total lymphocyte counts in the equation, CD8 levels became a significant risk factor (p = .004). Active treatment produced significant risk factor (p = .004). Active treatment produced significant improvements in those parameters related to total body and muscle mass (ie, mid arm muscle area, p = .02; creatinine height index, p = .03; percent ideal body weight, p = .04).


CONCLUSIONS
Deterioration in nutritional parameters is a significant risk factor for survival in severe patients with alcoholic hepatitis. This deterioration is reversible with standard hospital care. Active therapy further improves creatinine height index, mid arm muscle area and total lymphocyte counts. Hence, these later parameters appear to be the best indicators for follow-up assessments.
Department of Veterans Affairs Medical Centers: Cincinnati, Ohio 45220, USA.
C L
CL
Mendenhall
T E
TE
Moritz
G A
GA
Roselle
T R
TR
Morgan
B A
BA
Nemchausky
C H
CH
Tamburro
E R
ER
Schiff
C J
CJ
McClain
L S
LS
Marsano
J I
JI
Allen
D000328:Adult; D045930:Anabolic Agents / Q000592:standards / Q000627:therapeutic use*; D001772:Blood Cell Count; D015704:CD4 Antigens / Q000032:analysis; D016827:CD8 Antigens / Q000032:analysis; D003131:Combined Modality Therapy; D004311:Double-Blind Method; D002149:Energy Intake; D018737:Hand Strength / Q000502:physiology; D006519:Hepatitis, Alcoholic / Q000150:complications* / Q000503:physiopathology; D006801:Humans; D016131:Lymphocyte Subsets / Q000276:immunology / Q000473:pathology; D008297:Male; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000502:physiology; D010074:Oxandrolone / Q000592:standards / Q000627:therapeutic use*; D011502:Protein-Energy Malnutrition / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy*; D012044:Regression Analysis; D012885:Skinfold Thickness
D045930:Anabolic Agents; D015704:CD4 Antigens; D016827:CD8 Antigens; D010074:Oxandrolone