title: Risk factors for elevated liver enzymes during refeeding of severely malnourished patients with eating disorders: a retrospective cohort study.
abstract: BACKGROUND
  There are few previous reports regarding the cause and evolution of liver injury in patients with anorexia nervosa (AN) during the refeeding process, and its management remains controversial. This study aimed to determine the risk factors for elevated liver enzymes during refeeding and their effect on the therapeutic process in severely malnourished patients with eating disorders.
  
  
  METHODS
  In a retrospective cohort study of 167 female inpatients in a single hospital from January 2004 to March 2015, 67 who had normal alanine aminotransferase (ALT) levels on admission were divided into two groups according to the presence or absence of elevated ALT levels during refeeding, and then compared.
  
  
  RESULTS
  The median age and body mass index (BMI) of the patients on admission were 22 [interquartile range (IQR), 16-33] years and 12.2 (IQR, 11.1-13.0) kg/m2, respectively. Compared with their cohorts, significantly more patients in the early onset age group (<15 years old) had elevated ALT levels during refeeding (67% vs. 33%,p= 0.033), as did patients with longer median time to nadir BMI (3.0 vs. 0 days,p= 0.03). In addition, onset age [odds ratio (OR): 0.274; 95% confidence interval (CI): 0.077-0.981;p= 0.047] and time to nadir BMI (OR: 1.271; 95% CI: 1.035-1.56;p= 0.022) were significantly associated with the odds of elevated ALT levels during refeeding.
  
  
  CONCLUSIONS
  The results of this study suggest that early age at onset may be a potential risk factor for elevated ALT levels during refeeding in severely malnourished patients with eating disorders. Furthermore, elevated ALT levels during refeeding were significantly associated with delay in the start of weight gain. No significant relationship was found between the amount of initial prescribed calories and elevated ALT levels during refeeding. The median time to maximum ALT was 27 (IQR, 21-38) days after the refeeding process started.
authors.affiliation: Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya, Aichi 466-8550 Japan ; Sakura Clinic, 5-6 Dankeidori, Showa, Nagoya, Aichi 466-0842 Japan.
authors.forename: Miho
authors.initials: M
authors.lastname: Imaeda
authors.affiliation: Department of Psychiatry, Nagoya University Hospital, 65 Tsurumai, Showa, Nagoya, Aichi 466-8550 Japan.
authors.forename: Satoshi
authors.identifier: 0000-0002-7101-0690
authors.initials: S
authors.lastname: Tanaka
authors.affiliation: Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya, Aichi 466-8550 Japan.
authors.forename: Hiroshige
authors.initials: H
authors.lastname: Fujishiro
authors.affiliation: Saku Central Hospital, 197 Usuda, Saku, Nagano 384-0301 Japan.
authors.forename: Saki
authors.initials: S
authors.lastname: Kato
authors.affiliation: Department of Gastroenterology and Hepatology, Nagoya University Hospital, 65 Tsurumai, Showa, Nagoya, Aichi 466-8550 Japan.
authors.forename: Masatoshi
authors.initials: M
authors.lastname: Ishigami
authors.affiliation: Institute of Innovation for Future Society, Nagoya University, Furocho, Chikusa, Nagoya, Aichi 464-8601 Japan.
authors.forename: Naoko
authors.initials: N
authors.lastname: Kawano
authors.affiliation: Department of Neuropsychiatry, Faculty of Medical Sciences, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji, Yoshida, Fukui 910-1104 Japan.
authors.forename: Hiroto
authors.initials: H
authors.lastname: Katayama
authors.affiliation: Seichiryo Hospital, 16-27 Tsurumai 4, Showa, Nagoya, Aichi 466-0064 Japan.
authors.forename: Kunihiro
authors.initials: K
authors.lastname: Kohmura
authors.affiliation: Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, 65 Tsurumai, Showa, Nagoya, Aichi 466-8550 Japan.
authors.forename: Masahiko
authors.initials: M
authors.lastname: Ando
authors.affiliation: National Hospital Organization Higashi Owari National Hospital, 1301 Omorikita 2, Moriyama, Nagoya, Aichi 463-0802 Japan.
authors.forename: Kazuo
authors.initials: K
authors.lastname: Nishioka
authors.affiliation: Department of Psychiatry, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya, Aichi 466-8550 Japan.
authors.forename: Norio
authors.initials: N
authors.lastname: Ozaki
keywords: Anorexia nervosa; Eating disorder; Liver enzymes; Liver injury; Refeeding