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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 36-45

Assessment of the nutritional status and serum leptin level of hepatitis C virus-infected Egyptian patients with and without schistosomal hepatic periportal fibrosis


1 Department of Internal Medicine, Medical Research Institute, Alexandria, Egypt
2 Department of Parasitology, Medical Research Institute, Alexandria, Egypt
3 Department of Biochemistry, Medical Research Institute, Alexandria, Egypt

Date of Submission12-Dec-2015
Date of Acceptance14-Apr-2016
Date of Web Publication22-Jun-2016

Correspondence Address:
Said A Ooda
Department of Internal Medicine, Medical Research Institute, 165 Horreya Avenue, Hadara, Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2356-8062.184403

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  Abstract 


Background
Schistosomiasis has been a major public health problem in Egypt. Moreover, Egypt has been widely regarded as having the highest recorded prevalence of hepatitis C virus (HCV) in the world. Malnutrition is prevalent in all forms of liver disease.
Objective
The aim of the work was to assess the nutritional status of HCV-infected patients with and without schistosomal hepatic periportal fibrosis.
Patients and methods
This study was carried out on 93 men. A total sample size of 93 patients was taken. The patients were divided into three groups of 31 each: group I included 31 patients having HCV; group II included 31 patients having mixed schistosomal hepatic periportal fibrosis and HCV; and group III included 31 healthy controls. Serum leptin was measured. Abdominal ultrasonography was performed to all participants to detect the degree of fibrosis according to the WHO scoring system. Nutritional assessment was carried out using anthropometric measurements. Body fat content was measured using bioelectrical impedance analysis.
Results
This study showed that the fat content was higher in group I than in group II and was higher in controls than in patients. Serum leptin level was significantly higher in group II than in group I.
Conclusion
Affection with HCV and/or schistosomal hepatic periportal fibrosis affects the nutritional status of the individuals affected, with more pronounced nutritional derangement in patients with both diseases.

Keywords: bioelectrical impedance analysis, hepatitis C, leptin, periportal fibrosis


How to cite this article:
Ooda SA, Mohamed MA, Nabi MA, Lotfy WM, Alhabet BA. Assessment of the nutritional status and serum leptin level of hepatitis C virus-infected Egyptian patients with and without schistosomal hepatic periportal fibrosis. Egypt J Obes Diabetes Endocrinol 2016;2:36-45

How to cite this URL:
Ooda SA, Mohamed MA, Nabi MA, Lotfy WM, Alhabet BA. Assessment of the nutritional status and serum leptin level of hepatitis C virus-infected Egyptian patients with and without schistosomal hepatic periportal fibrosis. Egypt J Obes Diabetes Endocrinol [serial online] 2016 [cited 2020 Jul 9];2:36-45. Available from: http://www.ejode.eg.net/text.asp?2016/2/1/36/184403




  Introduction Top


Schistosomiasis has been a major public health problem in Egypt [1]. It affects child development and adult productivity. Schistosomiasis continues to be a significant cause of morbidity and mortality. The WHO considers schistosomiasis as second only to malaria in socioeconomic importance worldwide and the third more frequent parasitic disease in public health importance [2].

Beginning in the 1950s and continuing until the 1980s, the Egyptian Ministry of Health conducted large campaigns using the standard treatment at that time, tartar emetic, as community-wide therapy, not properly sterilized, and thus transferred traces of blood and blood-borne pathogens from human to human. As a result, this massive effort to control one health problem resulted in the creation of another, as hepatitis C virus (HCV) was spread through the intravenous injections. Indeed, this is estimated to be the largest known iatrogenic transmission of blood-borne infections in the history of the world [3].

With high prevalence rates for both HCV and schistosomiasis, it is inevitable that Egypt has a large number of humans with both diseases. Having both is more damaging to the liver and is associated with higher mortality rates than that having just one [4].

Nutrition status is recognized as a predictor of morbidity and mortality in patients with advanced liver disease [5]. The liver is an important regulator of metabolism, storage, synthesis, and absorption of nutrients. Accordingly, the severity of malnutrition increases with decreases in liver function. Malnutrition is prevalent in all forms of liver disease: from 20% in compensated liver disease to more than 80% in those patients with decompensated liver disease [6]. Many patients have subtle changes such as fat-soluble vitamin deficiency, altered cell-mediated immune function, anemia from iron, folate or pyridoxine deficiency, and minimal loss of muscle mass. Patients with end-stage liver disease have muscle wasting, decreased fat stores, and cachexia [7].

Leptin, the adipocyte-derived protein product, is involved in appetite regulation and obesity through central effects at the hypothalamus. Leptin is related to amount of body fat (BF) [8].

Bioelectrical impedance analysis (BIA) is a commonly used method for estimating body composition, and, in particular, BF. Since the advent of the first commercially available devices in the mid-1980s, the method has become popular owing to its ease of use, portability of the equipment, and its relatively low cost compared with some of the other methods of body composition analysis. It is familiar in the consumer market as a simple instrument for estimating BF. BIA actually determines the electrical impedance, or opposition to the flow of an electric current through body tissues, which can then be used to calculate an estimate of total body water [9],[10].


  Aim of the Study Top


The aim of this study was to evaluate the nutritional status of HCV-infected patients in association with schistosomal hepatic periportal fibrosis.


  Patients and Methods Top


This study was carried out on 93 men. The men were chosen because they have the same fat percentage. They were recruited from patients attending the Hepatology Department Clinic of Medical Research Institute, Alexandria University. All participants were asked to freely volunteer to the study and informed written consent was obtained before inclusion in the study, according to the ethical guidelines of Medical Research Institute, Alexandria University. A total sample size of 93 patients was taken. The study included three groups: group I, which included 31 patients with HCV; group II which included, 31 patients with mixed schistosomal hepatic periportal fibrosis and HCV; and group III, which included 31 healthy controls. Their ages ranged from 20 to 65 years.

All participants were subjected to the following and then assigned to the corresponding group.

  1. History and clinical examination



    1. An information sheet was prepared for each patient.
    2. Full history taking and thorough clinical examination were carried out.


  2. Abdominal ultrasonography to detect the degree of periportal fibrosis of schistosomiasis according to the WHO scoring system [11].
  3. Parasitological examination



    1. Stool examination using sedimentation and Kato-Katz techniques [12].
    2. Serology for schistosomiasis using the enzyme-linked immunosorbent assay technique [13].
  4. Nutritional assessment



    1. Anthropometric measurements

      1. Height.
      2. Weight.
      3. BMI [14].
      4. Waist and hip circumference.
      5. Waist–hip ratio.
    2. Body composition measurement



      BF was measured using BIA. The BF loss monitor OMRON HBF-306 C (Omron Healthcare, Lake Forest, Illinois, USA) device was used. This measurement is performed after entering the age, height, and sex into the device and then the patient holds the device with his hands to calculate the fat percentage. The Omron BF loss monitor may underestimate BF by about 3% in comparison with measurement taken using calipers, as reported by the manufacturer [15].


    In men, BF percentage below 13% is considered below average [16].



  • Biochemical examination.
  • Blood sample was drawn and the following investigations were performed.





  1. HCV infection was diagnosed by the presence of HCV antibodies using the enzyme-linked immunosorbent assay technique and confirming that using PCR for HCV.
  2. Complete blood count.
  3. Liver enzymes [alanine transaminase (ALT), aspartate transaminase (AST)].
  4. Serum albumin.
  5. Lipid profile (LDL, HDL, and total cholesterol, triglycerides).
  6. Serum leptin [8].The results were tabulated and analyzed according to the appropriate biostatistical methods.



  Results Top


Statistical analysis of the data

Data were fed into the computer and analyzed using SPSS software (version 20.0; SPSS Inc., Chicago, Illinois, USA) package for the social science, version 20.0. Qualitative data were described using number and percentage. Quantitative data were described using range (minimum and maximum), mean, SD, and median. Comparison between different groups as regards categorical variables was made using the c 2-test. When more than 20% of the cells have expected count less than 5, correction for c 2 was conducted using Fisher's exact test or Monte Carlo correction. The distributions of quantitative variables were tested for normality using the Kolmogorov–Smirnov test, Shapiro-Wilk test, and D'Agstino test. In addition, histogram and QQ plot were used for vision test. If it revealed normal data distribution, parametric tests were applied. If the data were abnormally distributed, nonparametric tests were used. For normally distributed data, comparisons between the studied groups were made using F-test (analysis of variance) and post-hoc test (Scheffe). For abnormally distributed data, the Kruskal–Wallis test was used to compare the studied groups and pair-wise comparison was assessed using the Mann–Whitney test. Significance test results are quoted as two-tailed probabilities. Significance of the obtained results was judged at the 5% level.

Age distribution

There was no statistical difference between the three studied groups with regard to age ([Table 1]).
Table 1: Age distribution among the studied groups

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Clinical presentation

There was no statistical difference between the studied groups with regard to the clinical presentation ([Table 2]).
Table 2 Clinical presentation of the studied groups

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Anthropometric measurements

[Table 3] shows the anthropometric data of the different studied groups.
Table 3: Anthropometric data of the different studied groups

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There was no statistical difference between the three studied groups with regard to height.

There was a significant statistical difference between the three studied groups with regard to weight. The highest mean weight was seen in controls and the lowest mean weight was seen in group II. Pair-wise comparison test denoted that there was a difference in the mean weight, being lower in group II compared with group III.

There was a significantly high statistical difference between the three studied groups with regard to waist circumference. The highest mean waist circumference was seen in controls and the lowest mean waist circumference was seen in group II. Pair-wise comparison test denoted that there was a difference in the mean waist circumference; it was lower in group I compared with group III and lower in group II compared with group III.

There was a significant statistical difference between the three studied groups with regard to hip circumference. The highest mean hip circumference was seen in controls and the lowest mean hip circumference was seen in group I. Pair-wise comparison test denoted that there was a difference in the mean hip circumference, being lower in group I compared with group III.

There was a significantly high statistical difference between the three studied groups with regard to waist–hip ratio. The highest waist–hip ratio was seen in controls and the lowest waist–hip ratio was seen in group II. Pair-wise comparison test denoted that there was a difference in the waist–hip ratio; it was greater in group I compared with group II, lower in group I compared with group III, and lower in group II compared with group III [Figure 1].
Figure 1: Comparison between the studied groups with regard to W/H. W/H, waist–hip ratio.

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There was a significant statistical difference between the three studied groups with regard to BMI. The highest BMI was seen in controls and the lowest BMI was seen in group II. Pair-wise comparison test denoted that there was a difference in the BMI, being lower in group II compared with group III [Figure 2].
Figure 2: Comparison between the studied groups with regard to BMI.

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Ultrasound findings

[Table 4] shows the ultrasound findings between the studied groups.
Table 4: Ultrasound findings between the studied groups

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There was a significantly high statistical difference between the three studied groups. Pair-wise comparison test denoted that there was a difference in the liver structure between groups II and III as well as between groups II and III.

There was no statistical difference between the three studied groups with regard to right lobe liver diameter.

There was a significantly high statistical difference between the three studied groups with regard to portal vein diameter. Pair-wise comparison test denoted that there was a difference in the portal vein diameter; it was lower in group I compared with group II, greater in group I compared with group III, and greater in group II compared with group III.

In group II, 74.2% of patients had grade I liver fibrosis and 25.8% had grade II liver fibrosis. Pair-wise comparison test denoted that there was a difference in the degree of liver fibrosis between groups I and III as well as between groups II and III.

There was no statistical difference between the three studied groups.

There was a significantly high statistical difference between the three studied groups with regard to spleen diameter. Pair-wise comparison test denoted that there was a difference in the spleen diameter; it was greater in group I compared with group II and greater in group II compared with group III.

Complete blood picture

[Table 5] shows the complete blood picture of the studied groups.
Table 5: Comparison between the studied groups with regard to CBC

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There was a significantly high statistical difference between the three studied groups with regard to red blood cell count. Pair-wise comparison test denoted that there was a difference in the red blood cell count; it was greater in group I compared with group II, lower in group I compared with group III, and lower in group II compared with group III.

There was a significantly high statistical difference between the three studied groups with regard to hemoglobin concentration. Pair-wise comparison test denoted that there was a difference in the hemoglobin concentration; it was greater in group I compared with group II, lower in group I compared with group III, and lower in group II compared with group III.

There was no statistical difference between the three studied groups with regard to white blood cell count. Pair-wise comparison test denoted that there was a difference in the white blood cell count; it was greater in group I compared with group II and lower in group II compared with group III.

There was a significantly high statistical difference between the three studied groups with regard to platelet count. Pair-wise comparison test denoted that there was a difference in the mean platelet count; it was greater in group I compared with group II, lower in group I compared with group III, and lower in group II compared with group III.

Liver functions

[Table 6] shows the liver functions of the studied groups.
Table 6: Comparison between the studied groups with regard to liver functions

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There was a significantly high statistical difference between the three studied groups with regard to ALT level. Pair-wise comparison test denoted that there was a difference in the mean ALT level; it was lower in group I compared with group II, greater in group I compared with group III, and greater in group II compared with group III.

There was a significantly high statistical difference between the three studied groups with regard to AST level. Pair-wise comparison test denoted that there was a difference in the mean AST level; it was lower in group I compared with group II, greater in group I compared with group III, and greater in group II compared with group III.

There was a significantly high statistical difference between the three studied groups with regard to albumin concentration. Pair-wise comparison test denoted that there was a difference in the mean albumin concentration; it was greater in group I compared with group II, lower in group I compared with group III, and lower in group II compared with group III [Figure 3].
Figure 3: Comparison between the studied groups with regard to albumin.

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All participants had normal serum bilirubin and prothrombin activity.

Lipid profile

[Table 7] shows the lipid profile of the studied groups.
Table 7: Comparison between the studied groups with regard to lipid profile

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There was no statistical difference between the three studied groups with regard to serum cholesterol and triglyceride concentration.

Leptin level

[Table 8] shows the leptin profile of the studied groups.
Table 8: Comparison between the studied groups with regard to leptin level

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There was a significant statistical difference between the three studied groups with regard to leptin level. Pair-wise comparison test denoted that there was a difference in the mean leptin level, being greater in group II compared with group III [Figure 4].
Figure 4: Comparison between the studied groups with regard to leptin level.

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Fat percentage

[Table 9] shows fat percentage in the different studied groups.
Table 9: Fat pnew ercentage of the different studied groups

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There was a significantly high statistical difference between the three studied groups with regard to fat percentage. The highest fat percentage was seen in controls and the lowest fat percentage was seen in group II. Pair-wise comparison test denoted that there was a difference in the fat percentage; it was greater in group I compared with group II, lower in group I compared with group III, and lower in group II compared with group III [Figure 5].
Figure 5: Comparison between the studied groups with regard to fat percentage.

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  Discussion Top


The present study aimed to evaluate the nutritional status of HCV-infected patients in association with schistosomal hepatic periportal fibrosis.

This study showed that the two studied groups (single infection and mixed infection) had malnutrition compared with the control group. The degree of malnutrition was more severe in group II, which had mixed schistosomiasis and HCV infections.

The chief reason for the malnutrition in these patients is poor oral intake, which may be due to a variety of causes. Vitamin A and or zinc deficiency may give rise to an altered sense of taste [17]. The dietary restrictions that are frequently advised to these patients, such as restriction of salt, protein, and fats, can discourage adequate oral intake by rendering food a bland taste. Weakness, fatigue, and encephalopathy may also contribute to decreased oral intake [18].

In addition, the loss of appetite may be related to the increased regulation of inflammation and of appetite mediators. Besides the hormonal influences and physical discomfort, the lack of interest in food may result from food restrictions and changes in taste [19].

Dietary limitations such as sodium restriction for the control of ascites, preoperative fast, and limitation of protein intake due to severe hepatic encephalopathy may reduce the variety of foods and many patients do not accept the recommended foods. Although changes in taste may be commonly attributed to micronutrient deficiencies, several investigators have questioned whether they might be a consequence of cirrhosis itself [19].

Malabsorption is another vital reason why patients with advanced hepatic disease become malnourished. A reduction in the bile-salt pool may lead to fat malabsorption [19], or bacterial overgrowth may result from impaired small-bowel motility [20]. Portal hypertension has also been named as a cause of malabsorption and protein loss from the gastrointestinal tract [21],[22].

Malabsorption may also be caused by pancreatic insufficiency and cholestasis and may be related to drugs that cause diarrhea (lactulose, antibiotics, diuretics, and cholestyramine). Several mechanisms can lead to the malabsorption of nutrients, fats in particular, in cirrhotic patients. A complication that affects nutrient absorption is the portosystemic shunt. With the progression of cirrhosis, the nutrients bypass the liver through the portosystemic shunt without being processed metabolically [23].

The functional integrity of the liver is essential for the utilization of nutrients. The liver influences the nutritional status by its production of bile acids and its role in the intermediate metabolism of proteins, carbohydrates, fats, and vitamins [24].

Among the metabolic disorders we may mention the following: hypermetabolism during complications such as infections, hemorrhage, decompensation, and ascites; increased protein catabolism due to inflammation and impaired hepatic synthesis; reduced glucose homeostasis due to hepatic insulin resistance caused by changes in gluconeogenesis, low glycogen stores, and impaired glycogenolysis; and increased lipolysis and lipid oxidation and proinflammatory cytokines (tumor necrosis factor α, interleukins, and leptin) [23].

Malnutrition may also be related to iatrogenic causes involved in investigative procedures, as well as to fasting periods, protein restriction during periods of encephalopathy, and to large volumes of paracentesis [23].

Energy expenditure is also known to contribute to the decline of nutritional status [23]. Although most cirrhotic patients have resting energy expenditure similar to predicted values, 15 to 30% of them are hypermetabolic. Hypermetabolism may be defined as an resting energy expenditure of 120% compared with predicted values [23].

The nutritional assessment of these patients is a challenge and should be performed with caution, as changes inherent to the liver disease itself, such as edemas, ascites, and protein changes, impair this task, preventing the use of the more traditional parameters for nutritional assessment. The 2006 guidelines of the European Society of Enteral and Parenteral Nutrition recommend the use of subjective global assessment, anthropometric analysis, and hand-grip strength test to identify patients with cirrhosis who are at risk for malnutrition. Thus, subjective global assessment, anthropometric measurements, and the hand-grip strength test are more commonly used in routine nutritional assessment. However, there is no gold-standard method of easy application and low-cost, without subjective data and not influenced by the professional who performs it [23].

Albumin and lipids are poor nutritional markers, because they are typically reduced in patients with advanced hepatic disease and fluctuate during periods of inflammation [23].

Leptin is an adipokine that contributes to the pathogenesis of liver steatosis. In patients with chronic hepatitis C, higher serum leptin concentrations have been associated with the presence of steatosis [25].

Several studies have shown that circulating leptin levels are modestly elevated in patients with alcoholic cirrhosis, suggesting that leptin might be involved in the malnutrition of cirrhosis [25]. Although some studies have supported these findings, others have reported low serum leptin levels in posthepatitis cirrhotic patients [26]. In addition, nutritional status of cirrhotic cases represents a wide range in normal-to-severe malnutrition, connected with severity of the disease. It appears that relationship of serum leptin levels and nutritional status in posthepatitis cirrhosis has not been fully clarified yet [27].

In a recent study, Fernandes et al. [28] found that the BIA is the only way for nutritional assessment that is correlated with the severity of hepatic disease assessed using the Child–Pugh classification and for the classification of malnutrition in the population of cirrhotic patients.

Thus, the interest in comparing the BIA with other methods used for the nutritional assessment of cirrhotic patients is clearly justified, to obtain data about its performance as an indicator of the nutritional status of these patients. In addition, a precise, low-cost, and reproducible nutritional parameter could be included in the Child–Pugh and model for end-stage liver disease equations, contributing to a better prognosis for patients.


  Conclusion Top


This study showed that the patients infected by HCV with and without schistosomal periportal fibrosis have malnutrition compared with healthy controls. The degree of malnutrition was more severe in patients having mixed schistosomal periportal fibrosis and HCV infections.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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Introduction
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