Enfermedad hepática en la fibrosis quística pediátrica. Una revisión de los conocimientos actuales / Cystic fibrosis liver disease in children ­ A review of our current understanding

La fibrosis quística, la segunda enfermedad genética más frecuente, es el resultado de una proteína de canal mutada, la CFTR, que secreta iones de cloro que fluidifican las secreciones. La esperanza de vida en los pacientes ha aumentado en años recientes gracias a mejoras en el tratamiento. No obstante, las complicaciones hepáticas son la tercera causa de muerte y la comprensión de su fisiopatología es aún deficiente. Se considera que la obstrucción biliar secundaria a la presencia de secreciones espesas conduce a la cirrosis. Sin embargo, el ácido ursodesoxicólico no ha modificado la historia natural. Además, la presencia de hipertensión portal en ausencia de cirrosis no puede ser explicada. Se ha propuesto el rol de la CFTR como modulador de tolerancia inmune, que explica la presencia de una inflamación portal persistente que culmina en fibrosis. El eje intestino-hígado tendría un rol importante en la presentación y la progresión de esta enfermedad

Cystic fibrosis is the second most common genetic disease in infancy. It is the result of a mutated channel protein, the CFTR, which secretes chloride ions, fluidifying secretions. Recent improvements in the treatment have increased life expectancy in these patients. Nevertheless, liver involvement remains the third cause of death. Unfortunately, our understating of the physiopathology is still deficient. Biliary obstruction secondary to the presence of thick secretions is considered to lead to cirrhosis. However, treatment with ursodeoxycolic acid has not changed the natural history. Furthermore, the presence of portal hypertension in the absence of cirrhosis cannot be explained. Recently, the role of CFTR as modulator of immune tolerance has been proposed, which could explain the presence of a persistent portal inflammation leading to fibrosis, and the gut-liver axis would also have a role in disease presentation and progression.

Advances in the diagnosis, treatment, and prognosis of acute decompensatory cirrhosis / 中华肝脏病杂志

Acute decompensatory cirrhosis is a common cause of hospital admission, readmission, and death, causing a heavy burden on patients, their families, and society. This article reviews the research advancement from the perspectives of concept evolution, pathogenesis, treatment, outcome, and prognosis models, providing new ideas for preventing and treating acute decompensatory cirrhosis.

Guía para el seguimiento de pacientes pediátricos con enfermedad hepática crónica / Guidelines for the follow-up of pediatric patients with chronic liver disease

La historia natural de la enfermedad hepática crónica (EHC) se caracteriza por una fase de cirrosis compensada asintomática seguida de una fase descompensada, que se acompaña de signos clínicos evidentes, de los cuales los más frecuentes son la ascitis, las hemorragias, la encefalopatía y la ictericia. Esta guía actualizada sobre el manejo de pacientes con EHC en la edad pediátrica fue confeccionada con el propósito de mejorar la práctica clínica de estos pacientes complejos y darle herramientas al pediatra de cabecera para un seguimiento adecuado. Para ello, un grupo de expertos subrayó la importancia del inicio temprano del tratamiento etiológico en cualquier grado de enfermedad hepática y ampliaron su labor jerarquizando las complicaciones de la cirrosis: ascitis, hemorragia digestiva, infecciones, malnutrición; aspectos endocrinológicos, neurológicos, oftalmológicos y gastrointestinales; y complicaciones vasculares pulmonares y renales. Se incluyeron, además, aspectos psicosociales, así como el cuidado del adolescente en su transición a la vida adulta.

The natural history of chronic liver disease (CLD) is characterized by a phase of asymptomatic compensated cirrhosis followed by a decompensated phase, accompanied by the development of evident clinical signs, the most frequent being ascites, hemorrhages, encephalopathy and jaundice. This updated guideline on the management of pediatric patients with CLD was developed with the purpose of improving the clinical practice of these complex patients and to provide the pediatrician with tools for an adequate follow-up. To this end, a group of experts, after stressing the importance of early initiation of etiologic treatment in any degree of liver disease, expanded their work to include a hierarchy of complications of cirrhosis: ascites, gastrointestinal bleeding, infections, malnutrition, endocrinological, neurological, ophthalmological, gastrointestinal, pulmonary vascular and renal complications. Psychosocial aspects including the care of the adolescent in their transition to adult life were also included.

Current status, challenges and reflections on stem cell therapy for liver diseases / 中华肝脏病杂志

There are increasing number of clinical studies on the use of stem cells in the treatment of liver diseases. Most studies have shown that stem cells can significantly improve liver function and prolong survival in patients with decompensated cirrhosis and liver failure. However, the current study has high heterogeneity and few mechanistic research data, which cannot answer many key questions about stem cell therapy for liver diseases. This paper reviews the research status of stem cells, in order to clarify the existing problems and challenges, and puts forward some reflections and countermeasures, with hope to promote the clinical application of stem cells in the treatment of liver diseases.

Baveno VII - Renewing consensus in portal hypertension: personalized care for portal hypertension / 中华肝脏病杂志

The Baveno VII workshop held in October 2021 was featured by the subject of personalized care in portal hypertension. The workshop focused on the following 9 topics including: the relevance and indications for measuring the hepatic venous pressure gradient as a gold standard; the use of non-invasive tools for the diagnosis of compensated advanced chronic liver disease and clinically significant portal hypertension; the impact of etiological and of non-etiological therapies in the course of cirrhosis; the prevention of the first episode of decompensation; the management of the acute bleeding episode; the prevention of further decompensation; as well as the diagnosis and management of splanchnic vein thrombosis and other vascular disorders of the liver. This essay provides a compilation and summary of recommendations regarding the abovementioned topics, and presents the most recent research proceedings and the corresponding consensus to our readers.

Alterações hidroeletrolíticas em pessoas com cirrose / Hydroelectrolytic alterations in cirrhotic patients

O objetivo deste estudo foi evidenciar e discutir as principais alterações hidroeletrolíticas em pessoas com cirrose. Trata-se de uma revisão integrativa, de natureza qualitativa. Os artigos foram selecionados por meio da plataforma Medical Literature Analysis and Retrievel System Online. Os principais achados identificados a partir dos artigos selecionados foram a ocorrência de hiponatremia, o mau prognóstico diante da presença de distúrbios hidroeletrolíticos em relação à sobrevida em pessoas com cirrose e a importância da albumina. Indivíduos com cirrose são suscetíveis ao desenvolvimento de distúrbios hidroeletrolíticos devido às mudanças fisiopatológicas da doença e às condições clínicas apresentadas. A hiponatremia e a hipocalemia são os mais recorrentes, destacando, porém, a necessidade de atenção aos demais distúrbios. (AU)

The objective of this study was to show and discuss the main hydroelectrolytic alterations in cirrhotic patients. This is an integrative review, a qualitative study, in which articles were selected at the Medical literature Analysis and Retrieval System Online. The main findings identified in the articles selected were the occurrence of hyponatremia, the poor prognostic, due to the presence of hydroelectrolytic disorders, regarding cirrhotic individuals survival and the importance of albumin. Individuals with cirrhosis are susceptible to the development of hydroelectrolytic disorders due to the pathophysiological alterations of the disease and because of the clinical status presented. Hyponatremia and hypokalemia are the most recurrent, but attention shall be given to the other disorders too. (AU)

Physiopathological and diagnostic aspects of cirrhotic cardiomyopathy / Aspectos fisiopatológicos y diagnósticos de la miocardiopatía cirrótica

Abstract Cirrhotic cardiomyopathy is characterized by the presence of structural and functional cardiac alterations in patients suffering from hepatic cirrhosis, without previously known cardiac causes that may explain it. Clinically, it is characterized by the presence of variable grades of diastolic and systolic dysfunction (SD), alterations in the electric conductance (elongation of corrected QT interval) and inadequate chronotropic response. This pathology has been related to substandard response in the management of patients with portal hypertension and poor outcome after transplant. Even when the first description of this pathology dates back from 1953, it remains a poorly studied and frequently underdiagnosed entity. Echocardiography prevails as a practical diagnostic tool for this pathology since simple measurements as the E/A index can show diastolic dysfunction. SD discloses as a diminished ejection fraction of the left ventricle and the latent forms are detected by echocardiography studies with pharmacological stress. In recent years, new techniques such as the longitudinal strain have been studied and they seem promising for the detection of early alterations.

Resumen La miocardiopatía cirrótica se caracteriza por la presencia de alteraciones cardiacas estructurales y funcionales en pacientes con cirrosis hepática, sin que existan otras causas de enfermedad cardiaca. Clínicamente se caracteriza por la presencia de grados variables de disfunción diastólica y sistólica, alteraciones de la conducción eléctrica (prolongación del intervalo QT) y respuesta cronotrópica inapropiada. Esta patología se ha relacionado con desenlaces clínicos adversos, mala respuesta en el manejo de la hipertensión portal y resultados desfavorables posterior a trasplante hepático ortotópico. A pesar de que las primeras descripciones datan de 1953, es una entidad poco estudiada y frecuentemente subdiagnosticada. El ecocardiograma es una herramienta de diagnóstico importante en esta entidad. Mediciones simples como el índice E/A pueden traducir disfunción diastólica. La disfunción sistólica se manifiesta con disminución de la fracción de eyección del ventrículo izquierdo y las formas latentes se detectan mediante estudios de ecocardiografía con estrés farmacológico; en los últimos años se han estudiado otras técnicas como el strain longitudinal, que parecen prometedoras en la detección de alteraciones tempranas.

Chapter of Gastroenterologists professional guidance for management of patients with liver disease in Singapore during the COVID-19 pandemic

In this paper, we aim to provide professional guidance to clinicians who are managing patients with chronic liver disease during the current coronavirus disease 2019 (COVID-19) pandemic in Singapore. We reviewed and summarised the available relevant published data on liver disease in COVID-19 and the advisory statements that were issued by major professional bodies, such as the American Association for the Study of Liver Diseases and European Association for the Study of the Liver, contextualising the recommendations to our local situation.

Cirrhotic cardiomyopathy: the liver affects the heart

Cirrhotic cardiomyopathy historically has been confused as alcoholic cardiomyopathy. The key points for diagnosis of cirrhotic cardiomyopathy have been well explained, however this entity was neglected for a long time. Nowadays the diagnosis of this entity has become important because it is a factor that contributes significantly to morbidity-mortality in cirrhotic patients. Characteristics of cirrhotic cardiomyopathy are a hyperdynamic circulatory state, altered diastolic relaxation, impaired contractility, and electrophysiological abnormalities, particularity QT interval prolongation. The pathogenesis includes impaired function of beta-receptors, altered transmembrane currents and overproduction of cardiodepressant factors, such as nitric oxide, cytokines and endogenous cannabinoids. In addition to physical signs of hyperdynamic state and heart failure under stress conditions, the diagnosis can be done with dosage of serum markers, electrocardiography, echocardiography and magnetic resonance. The treatment is mainly supportive, but orthotopic liver transplantation appears to improve this condition although the prognosis of liver transplantation in patients with cirrhotic cardiomyopathy is uncertain.

Fibrose hepática congênita e venopatia portal obliterativa sem hipertensão portal - revisão da literatura com base em um caso assintomático / Congenital hepatic fibrosis and obliterative portal venopathy without portal hypertension - a review of literature based on an asymptomatic case

ABSTRACT The disease and the case reported here are relevant especially because of their varied clinical presentation, possibility of being associated with other disorders affecting several organs and possible differential diagnoses. Congenital Hepatic Fibrosis is an autosomal recessive disease due to mutation in the PKHD1 gene, which encodes the fibrocystin/polyductine protein. It is a cholangiopathy, characterized by varying degrees of periportal fibrosis and irregular proliferation of bile ducts. Affected patients are typically diagnosed in childhood, but in some cases the disease may remain asymptomatic for many years. The exact prevalence and incidence of the disease are not known, but it is consider a rare disease, with a few hundred cases described worldwide. It can affect all ethnic groups and occur associated with various hereditary and non-hereditary disorders. The clinical presentation is quite variable, with melena and hematemesis being initial symptoms in 30%-70% of the cases. More rarely, they may present episodes of cholangitis. The disease has been classified into four types: portal hypertension, cholestasis / cholangitis, mixed and latent. Diagnosis begins with imaging tests, but the definition is made by the histopathological sample. So far, there is no specific therapy that can stop or reverse the pathological process. Currently, the therapeutic strategy is to treat the complications of the disease.

RESUMO A patologia e o caso aqui reportados são relevantes especialmente devido sua variada apresentação clínica, possibilidade de estar associada com outras desordens acometendo diversos órgãos e pelos possíveis diagnósticos diferenciais. A fibrose hepática congênita é uma doença autossômica recessiva, devido mutação no gene PKHD1, que codifica a proteína fibrocistina/poliductina. É uma colangiopatia, caracterizada por variados graus de fibrose periportal e proliferação irregular de ductos biliares. Os pacientes acometidos são tipicamente diagnosticados na infância, mas em alguns casos a doença pode permanecer assintomática por muitos anos. Exatas prevalência e incidência da doença não são conhecidas, mas sabe-se que é uma doença bastante rara, com algumas centenas de casos descritos no mundo. Pode afetar todos grupos étnicos e ocorrer associada com diversas desordens hereditárias e não-hereditárias. A apresentação clínica é bastante variável, com melena e hematêmese sendo sintomas iniciais em 30%-70% dos casos. Mais raramente, podem apresentar episódios de colangite. A doença tem sido classificada em quatro tipos: hipertensão portal, colestática/colangite, mista e latente. O diagnóstico inicia com exames de imagem, mas a definição é feita pela amostra histopatológica. Até o momento, não há terapia específica que possa parar ou reverter o processo patológico e a estratégia terapêutica atual é tratar as complicações da doença.

The Utilization of Palliative Care Services in Patients with Cirrhosis who have been Denied Liver Transplantation: A Single Center Retrospective Review

ABSTRACT Introduction and aim. Utilization of palliative care services in patients dying of end-stage liver disease (ESLD) is understudied. We performed a retrospective review of palliative care services among patients with ESLD unsuitable for liver transplantation (LT) at a tertiary care center. Material and methods. Deceased ESLD patients considered unsuitable for LT from 2007-2012 were identified. Patients were excluded if they received a transplant, had an incomplete workup, were lost to follow up or whose condition improved so LT was not needed. Of the 1,175 patients reviewed, 116 met inclusion criteria. Results. Forty patients (34.4%) received an inpatient palliative care (PC) consultation and forty-one patients (35.3%) were referred directly to hospice. Thirty-three patients (28.4%) transitioned to comfort measures without PC consultation (median survival < 1 day). The median interval between LT denial and PC consultation or hospice was 28 days. Median survival after PC consult or hospice referral was 15 days. In conclusion, in a single center retrospective review of ESLD patients, palliative care services, when utilized, were for care at the very end of life. Without consultation, aggressive interventions continued until hours before death. We propose that ESLD patients could benefit from PC consultation at time of LT evaluation or based on MELD scores.

Células madre mesenquimales y medicina regenerativa en la cirrosis hepática / Mesenchymal stem cells and regenerative medicine in liver cirrhosis

Las células madre mesenquimales (MSCs) son células multipotentes con capacidad de auto-renovación, presentes en diferentes tejidos del organismo. En los últimos años se ha avanzado significativamente en su estudio debido a su potencial terapéutico en medicina regenerativa. Las MSCs se caracterizan por migrar selectivamente a sitios de injuria y remodelación y por su capacidad para evadir al sistema inmunitario y colaborar en la reparación tisular mediante la secreción de factores tróficos. Numerosos estudios pre-clínicos y clínicos analizan su potencial efecto terapéutico en la cirrosis hepática con resultados alentadores. Diversas evidencias experimentales sugieren que este efecto podría ser superior si se utilizaran MSCs como vehículo de genes terapéuticos. En este trabajo se revisa el rol de las MSCs en medicina regenerativa y su empleo en estudios clínicos y pre-clínicos, con énfasis en su potencial como vehículo de genes terapéuticos.

Mesenchymal stem cells (MSCs) are multipotent cells with self-renewal capacity which are present in diverse tissues. Recently, significant progresses have been made in the field of MSCs because of its therapeutic potential in regenerative medicine. MSCs selectively migrate toward sites of damage and remodeling, and have the ability to evade the immune system and to promote tissue repair through the production of a number of growth factors and cytokines. Many pre-clinical and clinical studies have been carried out to study its therapeutic effect in liver cirrhosis with promising results. In addition, experimental studies showed that this therapeutic effect can be improved by engineering MSCs to produce therapeutic genes. In this work, the role of MSCs in regenerative medicine and its clinical and pre-clinical applications are reviewed, with an emphasis on its potential as vehicles for therapeutic genes.

Hernia Umbilical Asintomática en la Cirrosis Hepática / ASYMPTOMATIC UMBILICAL HERNIA IN LIVER CIRRHOSIS

La hernia umbilical es una complicación que puede constituirse en una amenaza para la vida en la cirrosis hepática. Aquí, demostramos dos interesantes casos de cirrosis hepática que se presentaron con hernia umbilical asintomática, pero que no fueron sometidos a ningún tipo de cirugía

Umbilical hernia is a life-threatening complication of liver cirrhosis. Herein, we demonstrated two interesting cases with liver cirrhosis that presented with asymptomatic umbilical hernia, but did not undergo any surgery.

Disfunción cardiaca en la cirrosis hepática / Cardiac dysfunction in liver cirrhosis

Objetivo: determinar las alteraciones de la función cardiaca en las personas que padecen cirrosis hepática. Métodos: se desarrolló un estudio descriptivo transversal en el Instituto de Gastroenterología durante el período 2011-2012, en 33 cirróticos de causa viral y alcohólica, 57,6 por ciento del sexo masculino, con una edad promedio de 50 años, la mayoría (84,8 por ciento) tenía la enfermedad compensada. Resultados: la disfunción diastólica fue la alteración cardiaca más frecuente (39,3 por ciento) seguida de la prolongación del intervalo QT (12,1 por ciento), disfunción sistólica (6,1 por ciento) y miocardiopatía cirrótica (3 por ciento). No se identificaron rasgos distintivos epidemiológicos y/o clínicos que caracterizara a estos pacientes. La circulación hiperdinámica fue más evidente en los que presentaron disfunción diastólica y en la cirrosis de origen alcohólico; las dimensiones cardiacas fueron normales en todos los casos. Conclusiones: las personas que padecen cirrosis son susceptibles de presentar alteraciones de la función cardiaca, incluso, desde la etapa compensada de la enfermedad, lo que debe considerarse por las implicaciones terapéuticas que demanda este tipo de paciente...

Objective: to determine abnormalities of cardiac function in subjects with liver cirrhosis. Methods: a descriptive cross-sectional study was conducted at the Institute of Gastroenterology from 2011 to 2012, in 33 cirrhotic patients due to alcoholic and viral causes, 57.6 percent male, with an average age of 50 years, most (84,8 percent) had compensated disease. Results: diastolic dysfunction was the most common cardiac disorders (39.3 percent) followed by QT prolongation (12.1 percent), systolic dysfunction (6.1 percent) and cirrhotic (3 percent) cardiomyopathy interval. No distinctive epidemiological and/or clinical studies were identified to characterize these patients. The hyperdynamic circulation was more evident in those presenting diastolic dysfunction and alcohol-related cirrhosis. Cardiac dimensions were normal in all cases. Conclusions: people with cirrhosis are susceptible to alterations in cardiac function, even from the compensated stage of the disease, which should be considered by the therapeutic implications of this type of patient demand...

Cirroses hepáticas metabólicas / Hepatic cirrhosis metabolic

A cirrose hepática é importante causa de morbidade e mortalidade em todo o mundo. Entre as principais etiologias destacam-se as hepatites crônicas pelos vírus da hepatite C (HCV) e B (HBV) e o consumo e abuso do álcool. Destacamos, também, as hepatites crônicas e cirroses de natureza autoimune, medicamentosas, dentre outras.

Liver cirrhosis is the most important cause of mortality and morbidity all over the world. Among the mainly etiologies, chronic hepatites highlight due hepatite C (HCV) and B (HBV) and alcohol abuse. We also emphasize chronic hepatitis and cirrhosis from autoimmune and medical origins, among others.

Esquistossomose hepática como achado ocasional de fígado de doador para transplante / Hepatic schistosomiasis as an occasional finding in a transplanted liver

Introdução: A prevalência de cirrose criptogênica varia de 5% a 30% dos pacientes cirróticos nas séries históricas. O transplante hepático representa a única opção em reverter a insuficiência hepatica e suas complicações em pacientes cirróticos em estágio avançado. A esquistossomose mansônica no Brasil é um problema endêmico de saúde pública, particularmente na região nordeste do país. Apresenta-se relato de caso de paciente do sexo masculino admitido ao Hospital Geral de Fortaleza, Ceará , Brasil, com cirrose criptogênica classificada como Child Turcotte-Pugh C, com MELD 25, submetido a transplante hepático com fígado de doador portador de esquistossomose como achado ocasional da biópsia padrão. Foi revisada a história clínica e exame físico na admissão, resultados de exames laboratoriais e dados do seguimento clínico. Como conclusão, as infecções parasitárias em órgãos sólidos transplantados tem aumentado nos últimos anos. É muito importante realizar o controle da qualidade dos órgãos e tecidos utilizados em transplantes, assim como desenvolver técnicas de diagnóstico, tratamento e profilaxia, especialmente em transplante hepático, em vista da alta prevalência de infecções parasitárias em nosso país, com intuito de prevenir outras co-morbidades e aumentar a sobrevida dos pacientes transplantados. Em regiões endêmicas, os potenciais doadores de receptores que têm esquistossomose ativa devem ser preventivamente tratados.

Introduction: The prevalence of cryptogenic cirrhosis ranges from 5% to 30% of cirrhotic patients in past series (CADWELL et al, 1999). Liver transplantation represents the only option to revert the hepatic insufficiency and its complications in cirrhotic patients in advanced stage. In Brazil, Mansonic Schistosomiasisis a public health problem and endemic disease, particularly in the Northeast of the country. Methods: Case report of a male patient, admitted to Hospital Geral de Fortaleza, Ceará, Brazil, with cryptogenic hepatic cirrhosis, classified as Child-Turcotte-Pugh C, with a MELD of 25, submitted to a liver transplantation, and found to have schistosomal hepatic disease on biopsy report. We reviewed the patient's medical history and physical examination on admission, prescription, results of laboratory tests and follow up data. Survey of the literature in national and international scientific journals helped incollecting information on this disease. Conclusions: Parasitic infections in solid organ transplant has increased in the recent years. It is very important to keep a strict control of the quality of the organs and tissues used in transplantations, as well as an improvement in diagnosis, treatment and prophylaxis techniques, especially in liver transplantation, in view of a high prevalence of parasitic infections in our country, in order to prevent the developmentof other comorbidities, and to increase the survival of transplanted patients. In endemic countries, potential donors or recipients who have active schistosomal infection should be preventively treated.

Evaluación nutricional de los pacientes con cirrosis hepática compensada atendidos en el Centro Hospitalario Regional de Mouila, Gabón, 2009-2010 / Nutritional assessment in patients with compensated liver cirrhosis treated at the Mouila Regional Hospital, Gabon, 2009-2010

Introducción: algunos investigadores consideran que la malnutrición proteico energética es la complicación más frecuente en el paciente cirrótico y que constituye un elemento predictor independiente de supervivencia. Objetivos: determinar el estado nutricional y su relación con la causa, el tiempo de evolución y la ingesta calórica en pacientes con cirrosis hepática compensada. Métodos: se realizó un estudio observacional descriptivo de todos los pacientes gaboneses de ambos sexos, entre 15 y 60 años, con este diagnóstico. Se halló predominio de las mujeres y del grupo entre 45 y 54 años, con una edad media de 45 años (± 7,6). Prevalecieron la causa mixta y el grupo A de la clasificación de Child-Pugh-Turcotte. Todos tenían menos de 1 año desde el diagnóstico de la enfermedad y según el índice de masa corporal, la malnutrición proteico-energética se observó en 75 por ciento de los casos, predominó la delgadez moderada. La circunferencia del brazo se afectó con menor frecuencia e intensidad que el índice de masa corporal. En la medida que disminuyó el número de comidas al día aumentó el porcentaje de pacientes con malnutrición proteico-energética. Conclusiones: la frecuencia de malnutrición de la población cirrótica compensada fue elevada, con mayor índice de malnutrición en los casos de causa mixta, además, se comprobó que el estado nutricional del paciente cirrótico no puede ser valorado al margen de factores dietéticos

Introduction: some researchers believe that protein energy malnutrition is the most common complication in cirrhotic patients and it is an independent predictor of survival element. Objectives: to determine the nutritional status and its relationship to the cause, time of evolution and caloric intake in patients with compensated liver cirrhosis. Methods: a descriptive study of all Gabonese patients of both sexes, between the ages 15 and 60 years, with this diagnosis. Women and the group between 45 and 54 years was found predominant (mean age 45 years (± 7.6)). Additionally, mixed cause and group A in Child-Pugh-Turcotte widely existed. All patients had diagnosis of this disease for less than a year and according to their body mass index, protein-energy malnutrition was observed in 75 percent of cases; moderate thinness predominated. The arm circumference was less frequently and intensively affected than the body mass index. To the extent that the number of meals reduced per day, the percentage of patients with protein-energy malnutrition increased. Conclusions: the frequency of malnutrition of compensated cirrhotic population was high, with the highest rate of malnutrition in cases of mixed causes; it also was proved that the nutritional status of cirrhotic patient cannot be valued regardless of dietary factors

Study of Zinc in Cirrhosis of Liver.

73 liver cirrhosis patients have been selected. Serum zinc and albumin levels were estimated in them in comparison to controls. Significant decrease in zinc and albumin levels were observed in liver cirrhosis patients. This work is an attempt to understand the important role that the zinc plays in the pathogenesis and therapy of liver cirrhosis and the role of albumin in zinc transport.