Hepatocellular Autophagy in Anorexia Nervosa (AN)

Abstract

Introduction: We report a rare entity of liver autophagy syndrome in a chronically starved patient recently started on oral feeding, since this can be a potentially fatal complication. Case Report: A 22-year-old female with AN was admitted from an inpatient psychiatry ward for failure to thrive with weight loss of 18 lbs over 2 months. She was started on a regular diet with close monitoring of electrolytes for re-feeding syndrome. On admission, the patient weighed 55 lbs with a height of 62 in and BMI of 10. She was found to have elevated liver function tests (see table). Her extensive work-up for abnormal liver function tests (LFTs) was unremarkable, and the patient was presumed to have hepatocellular autophagy. She was started on low protein and carbohydrate diet with frequent monitoring of her LFTs and electrolytes. Her diet was gradually increased with subsequent normalization of LFTs. Discussion: Autophagy results in the formation of autophagosomes, which fuse with lysosomes where degradation occurs. Autophagy is involved in cell homeostasis, and the best known role of autophagy is in its action during starvation. Macromolecules resulting from autophagy are presumably released from the vacuoles for reuse in the cytosol and are a source of continued biosynthesis. Autophagy also delays apoptosis in a cell during nutrient deprivation, and is a survival strategy under stress condition. However, recent studies have shown that autophagy can effectively kill a cell if the components are rapidly consumed as suspected in our patient. There are no guidelines in the management of acute liver injury in patients with anorexia nervosa. Improvement in LFTs has been reported with adequate nutritional support and close monitoring of electrolytes. Several authors recommend a low protein and carbohydrate diet with a theoretical benefit to prevent re-feeding steatosis. Anorexia nervosa with extremely poor nutritional status should be included in the differential diagnosis of acute liver injury. Our findings suggest that starvation-induced autophagy played a role in hepatocellular death resulting in acute liver injury.Table 1: Summary of Liver Function Tests