Negative Nitrogen Balance Research Articles

Effect of supplementation of concentrate to sweet sorghum bagasse with leaf residue silage on nutrient utilization and nitrogen balance in native sheep

The present study was carried out to evaluate the effect of supplementation of concentrate at different levels to sweet sorghum bagasse leaf residue (SSBLR) silage on nutrient utilization in growing lambs in a metabolism trial conducted after 120days of feeding. Sixteen growing Nellore ram lambs (18.3±0.8) were randomly allotted to 4 dietary groups (4 in each group) and were inducted into metabolic cages five days prior to collection for acclimatization followed by a seven day collection period. The four dietary groups were SSBLR silage fed ad libitum and supplemented with concentrate mixture (CP 17% and ME 2.53 Mcal/kg DM) at 0.0 (R-I), 0.75 (R-II), 1.0 (R-III) and 1.25 (R-IV) per cent of their live Weight. Significantly (P<0.01) higher total DMI (g/kg w0.75) was noticed in concentrate supplemented groups. The organic matter, crude protein and nitrogen free extract digestibility was significantly (P<0.05) higher in lambs fed R-IV ration than those fed R-I ration. No significant difference in the digestibility of dry matter, ether extract and cell wall constituents was observed among the rations. The digestible crude protein (%) (P<0.01) and metabolizable energy (Mcal/kg) values increased (P>0.0) with increase in level of concentrate in the diet. Negative and lower (P<0.01) nitrogen balance (g/d) was noticed in R-I ration. The N balance linearly increased with increase in level of concentrate supplementation. The study indicated feeding of sole SSBLR silage couldn't meet the nutrient requirements and Supplementation of concentrate mixture (0.75-1.25%) to SSBLR silage improved the nutrient digestibility and nitrogen balance in growing lambs.

Apparent digestibility and microbial protein yield of Desmodium uncinatum, Mucuna pruriens and Vigna unguiculata forage legumes in goats

This study examined the effects of adding forage legumes as protein supplements to poor-quality natural pasture (veld) hay offered to goats on microbial protein yield and nitrogen metabolism. Four indigenous Nguni-type goats were used in a 4×4 Latin cross-over design experiment. Goats were randomly allocated to four dietary treatments comprising commercial goat feed (GF), veld hay supplemented with cowpea (CW), velvetbean (VB) or silverleaf desmodium (SD). Microbial protein yields were determined using the purine derivatives technique and nitrogen retention was calculated from the digestible organic matter intake. Total nitrogen intake was significantly higher in the GF followed by CW, SD and VB, respectively. Microbial protein supply, calculated microbial true protein and digestible microbial true protein were affected (P<0.05) by legume supplementation. Animals on poor-quality forages had the most efficient microbial protein synthesis. However, supplementation of hay failed to meet the maintenance requirements of animals as evidenced by negative nitrogen balances in VB and SD. The efficiency of utilisation of nitrogen in the supplements could have been limited by unavailable fermentable metabolisable energy in the diets. Supplementation of poor-quality veld hay with legume forages could improve utilisation, especially in the dry season.

Strategies to improve tolerance to peri-operative enteral feeding

A major surgical procedure results in injury resulting in systemic response resulting in a negative nitrogen balance. The conventional management of a patient in the peri-operative period involves pre- and post-operative fasting, which potentiates the caloric deficit. Early feeding has been shown to result in a positive clinical outcome. How-ever, the physiologic response to surgery impedes successful initiation of early enteral feeds. This article discusses the various strategies to improve tolerance to early enteral feeds in the immediate post-operative period.

New Progress in Nursing for Early Enteral Nutrition after Esophageal Carcinoma Surgery

&lt;p&gt;Esophageal carcinoma drains the body, and its surgery causes dramatic trauma. After operation, patients must abstain from food. The body experiences negative nitrogen balance for a long time after operation due to fever, stress and loss of body fluids as well as digestive juices. Hence, nutritional support appears to be extremely important. Nurses needed to pay more attention in solving the problem of post-operative malnutrition. &lt;/p&gt;

Feeding the critically ill obese patient: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE The objective of this review is to identify effective enteral nutritional regimens targeting protein and calorie delivery for the critically ill obese patient on morbidity and mortality. More specifically, the review question is: In the critically ill obese patient, what is the optimal enteral protein and calorie target that improves mortality and morbidity? INCLUSION CRITERIA Types of participants This review will consider studies that include critically ill obese adult patients receiving enteral nutritional support at any stage during their Intensive Care Unit admission for a time period of greater than 72 hours. Studies eligible for retrieval will include intensive care patients in intensive care units or alternatively using a population of patients in which greater than or equal to 50% of trial participants required mechanical ventilation. In attempting to limit the search to studies involving critically ill patients in this way, it is acknowledged that there are differing criteria that determine Intensive Care Unit admission between countries determined in part by resources, in part by cultural differences and in part by the model of intensive care that predominates (closed versus open Intensive Care Units). This is, however, a universal conundrum of critical care research in which there is often heterogeneity in admission diagnosis, severity of disease, metabolic derangement and therapeutic interventions, and which has been recognized in other publications. Critically ill populations comprising both elective and emergency Intensive Care Unit admissions will be included, as will critically ill populations with a medical or surgical TRUNCATED AT 250 WORDS

Randomized Phase II Study of the Anti-inflammatory Effect of Ghrelin During the Postoperative Period of Esophagectomy

A prospective randomized phase II trial was conducted to evaluate the efficacy of ghrelin administration in reducing systemic inflammatory response syndrome (SIRS) duration after esophagectomy. Esophagectomy for esophageal cancer is highly invasive and leads to prolonged SIRS duration and postoperative complications. Ghrelin has multiple effects, including anti-inflammatory effects. Forty patients undergoing esophagectomy were randomly assigned to either the ghrelin group (n = 20), which received continuous infusion of ghrelin (0.5 μg/kg/h) for 5 days, or the placebo group (n = 20), which received pure saline for 5 days. The primary endpoint was SIRS duration. The secondary endpoints were the incidence of postoperative complications, time of a negative nitrogen balance, changes in body weight and composition, and levels of inflammatory markers, including C-reactive protein (CRP) and interleukin-6 (IL-6). The ghrelin group had a shorter SIRS duration and lower CRP and IL-6 levels than did the placebo group. The incidence of pulmonary complications was lower in the ghrelin group than in the placebo group, whereas other complications did not differ between the groups. Although time of the negative nitrogen balance was shorter in the ghrelin group than in the placebo group, changes in total body weight and lean body weight did not differ significantly. Postoperative ghrelin administration was effective for inhibiting inflammatory mediators and improving the postoperative clinical course of patients with esophageal cancer.

Nutritional-metabolic factors affecting nitrogen balance and substrate utilization in the critically ill.

To determine clinical, anthropometric, metabolic, and nutritional factors affecting nitrogen balance somatic protein status and substrate utilization in critically ill children measured energy expenditure (MEE) was measured by indirect calorimetry within 24 hr of an acute illness, solid organ transplantation, or cardiovascular surgery. Predicted basal metabolic rate was calculated using the Schofield equation. Somatic protein was estimated by the creatinine-height index. Nitrogen balance (NB) was calculated by subtracting the total nitrogen input from output. The net substrate (fat, carbohydrate, and protein) oxidation rates were calculated using the Weir formula modified by Frayn. Sixty-eight NB studies, indirect calorimetric and anthropometric measurements performed in 37 patients. Nitrogen balance was worse when the MEE/Predicted basal metabolic rate ratio was < 0.9 or > 1.1. The incidence of negative NB was 91% when the caloric intake was less than MEE and 9% when it was equal to or greater than MEE (P < 0.05). On day 1, 27% had mild to moderate somatic protein depletion and 5.4% had severe somatic protein depletion. Only the persistence of stress and co-morbidity were associated with the creatinine-height index (P < 0.001). Without Multiple Organ System Failure (MOSF), there was a trend toward positive nitrogen balance by day 7 while with MOSF, negative nitrogen balance persisted even by day 7 (P < 0.05). When caloric intake was less than MEE, mean substrate utilization was 48.6% from lipid, 37.1% from carbohydrate, and 14.3% from proteins. But, when caloric intake was greater than MEE, mean substrate utilization was 83.3% from carbohydrate and 16.7% from protein. Significant negative nitrogen balance and somatic protein depletion develops in critically ill pediatric patients, especially when they are inadequately fed, develop MOSF, or have previous chronic illness. Caloric intake and MOSF independently affect substrate utilization.

Effect of feeding cactus-legume silages on nitrogen retention, digestibility and microbial protein synthesis in goats

The effect of co-ensiling Opuntia ficus indica with dry forage legumes on dry matter intake, digestibility, nitrogen retention and overall performance of kapaters was investigated. The treatment diets were Cactus-Acacia angusitissima silage (CAAS), Cactus-Leuceana leucocephala silage (CLLS), Cactus-Calliandra calothyrsus silage (CCCS), Cactus-Macroptilium atropuprium silage (CMAS) and a negative control of Pennisetum purpureum (PP) hay which was also fed as a basal diet to all other animals. Thirty, one-year old kapaters of mean (±SD) weight of 22.6kg (±5.41) were assigned to the five treatments in a completely randomised design. The goats were individually housed in metabolism cages for a period of twenty-one days adaptation and seven-days of total urine and faecal collection. The results showed a significantly (P<0.05) higher dry matter intake (DMI), organic matter intake and digestibility of organic matter (DOM) in goats fed cactus-forage legume silages diets than those fed Pennisetum purpureum hay alone. Mixed silages DMI ranged from 0.72 to 0.81kg/day and 0.42 to 0.50 DOM. The calculated microbial protein yield was highest in the CLLS group and lowest in the PP group. These trends are also reflected in the nitrogen intake (NI) and retention with CLLS (NI=16g/day, N retained=13.54g/day) showing the highest values and CMAS (NI=9.02g/day, N retained=6.11g/day) having the least among the silage supplemented goats. The PP fed goats had the least intake and a marginally negative nitrogen balance. Daily live weight gain was low (<100g/day) for all the diets. The Pennisetum purpureum group had a negative weight gain throughout the period. The resultant silages can improve animal performance especially during times of nutritional stress. We concluded that mixed cactus legumes silage can be used as supplements in periods of feed deficits to improve goat performance and communal livelihood.

Effect of dietary protein restriction on renal ammonia metabolism.

Dietary protein restriction has multiple benefits in kidney disease. Because protein intake is a major determinant of endogenous acid production, it is important that net acid excretion change in parallel during protein restriction. Ammonia is the primary component of net acid excretion, and inappropriate ammonia excretion can lead to negative nitrogen balance. Accordingly, we examined ammonia excretion in response to protein restriction and then we determined the molecular mechanism of the changes observed. Wild-type C57Bl/6 mice fed a 20% protein diet and then changed to 6% protein developed an 85% reduction in ammonia excretion within 2 days, which persisted during a 10-day study. The expression of multiple proteins involved in renal ammonia metabolism was altered, including the ammonia-generating enzymes phosphate-dependent glutaminase (PDG) and phosphoenolpyruvate carboxykinase (PEPCK) and the ammonia-metabolizing enzyme glutamine synthetase. Rhbg, an ammonia transporter, increased in expression in the inner stripe of outer medullary collecting duct intercalated cell (OMCDis-IC). However, collecting duct-specific Rhbg deletion did not alter the response to protein restriction. Rhcg deletion did not alter ammonia excretion in response to dietary protein restriction. These results indicate 1) dietary protein restriction decreases renal ammonia excretion through coordinated regulation of multiple components of ammonia metabolism; 2) increased Rhbg expression in the OMCDis-IC may indicate a biological role in addition to ammonia transport; and 3) Rhcg expression is not necessary to decrease ammonia excretion during dietary protein restriction.

Twenty-four hour hyperinsulinemic-euglycemic clamp improves postoperative nitrogen balance only in low insulin sensitivity patients following cardiac surgery.

Critically ill patients often suffer from a protein catabolic state. The aim of this study was to demonstrate that nitrogen balance (NB) in cardiac patients admitted to the intensive care unit (ICU) is related to their insulin sensitivity level and that supraphysiologic doses of insulin can restore anabolism. Twenty-eight patients that were admitted to ICU in enteral and/or parenteral nutrition have been enrolled in this study. All patients received a standard nutrition protocol for at least 3 days before starting the study. These patients received either enteral or parenteral nutrition based on 1.4kcal/kg/h and 1.1g/kg/24h of proteins. Participants were studied for three 24h periods (P1 , P2 , and P3 ). Twenty-four hour NB was calculated from urinary urea nitrogen excretion, fixed protein and energy intake during each of the three periods (P1 , P2 , and P3 ). Simultaneous to P2, a 24h hyperinsulinemic-euglycemic clamp (HEC) was performed to determine patients' insulin sensitivity (IS) or insulin resistance (IR), as well as the impact of high doses of insulin on NB. Nitrogen balance remained consistently positive in the IS group regardless of the clamp. In IR patients, NB was negative before the clamp and became positive during P2 and P3 . Insulin sensitivity improved during the HEC in IR patients (P<0.001). A negative NB was found only in insulin resistant patients admitted to the ICU for more than 7days. A 24-h period HEC improved NB in these patients.

Tuberculosis and vitamin D: what's the rest of the story?

Both protein–energy undernutrition and specific micronutrient deficiencies debilitate the cell-mediated immune system important in protection against tuberculosis.1 However, once tuberculosis develops, the disease itself induces a catabolic state resulting in negative nitrogen balance and micronutrient deficiencies. Generations of clinicians treating patients with tuberculosis believed that nutritional support was crucial to proper patient care. Why, then, has it been so difficult to prove through randomised controlled clinical trials that nutritional interventions improve tuberculosis treatment outcomes? Findings from systematic reviews2–6 have not shown any clear, consistent benefit in terms of tuberculosis-specific outcomes, although they do show improvements in nutritional status.

Pathologic metabolism: an exploratory study of the plasma metabolome of critical injury.

Severe trauma is associated with massive alterations in metabolism. Thus far, investigations have relied on traditional bioanalytic approaches including calorimetry or nuclear magnetic resonance. However, recent strides in mass spectrometry (MS)-based metabolomics present enhanced analytic opportunities to characterize a wide range of metabolites in the critical care setting. MS-based metabolomics analyses were performed on plasma samples from severely injured patients' trauma activation field blood and plasma samples obtained during emergency department thoracotomy. These were compared against the metabolic profiles of healthy controls. Few significant alterations were observed between trauma activation field blood and emergency department thoracotomy patients. In contrast, we identified trauma-dependent metabolic signatures, which support a state of hypercatabolism, driven by sugar consumption, lipolysis and fatty acid use, accumulation of ketone bodies, proteolysis and nucleoside breakdown, which provides carbon and nitrogen sources to compensate for trauma-induced energy consumption and negative nitrogen balance. Unexpectedly, metabolites of bacterial origin (including tricarballylate and citramalate) were detected in plasma from trauma patients. In the future, the correlation between metabolomics adaptation and recovery outcomes could be studied by MS-based approaches, and this work can provide a method for assessing the efficacy of alternative resuscitation strategies.

Disruption of bone and skeletal muscle in severe burns.

Severe burn injury triggers the body's nonspecific adaptive responses to acute insult, including the systemic inflammatory and stress responses, as well as the sympathetic response to immobilization. These responses trigger inflammatory bone resorption followed by glucocorticoid-induced apoptosis of osteoblasts and probably osteocytes. Because these patients are catabolic, they suffer concomitant muscle wasting and negative nitrogen balance. The use of anabolic agents such as recombinant human growth hormone and oxandrolone results in improved bone mineral content and muscle strength after approximately 1 year. Use of bisphosphonates within the first 10 days of a severe burn completely blocks the resorptive bone loss and has the added advantage of appearing to preserve muscle protein from excessive breakdown. The mechanism for the protective effect on muscle is not currently known. However, if the effect of bisphosphonates on muscle can be confirmed, it raises the possibility that bone communicates with muscle.

Inflammation, negative nitrogen balance, and outcome after aneurysmal subarachnoid hemorrhage.

To analyze the impact of inflammation and negative nitrogen balance (NBAL) on nutritional status and outcomes after subarachnoid hemorrhage (SAH). This was a prospective observational study of SAH patients admitted between May 2008 and June 2012. Measurements of C-reactive protein (CRP), transthyretin (TTR), resting energy expenditure (REE), and NBAL (g/day) were performed over 4 preset time periods during the first 14 postbleed days (PBD) in addition to daily caloric intake. Factors associated with REE and NBAL were analyzed with multivariable linear regression. Hospital-acquired infections (HAI) were tracked daily for time-to-event analyses. Poor outcome at 3 months was defined as a modified Rankin Scale score ≥ 4 and assessed by multivariable logistic regression. There were 229 patients with an average age of 55 ± 15 years. Higher REE was associated with younger age (p = 0.02), male sex (p < 0.001), higher Hunt Hess grade (p = 0.001), and higher modified Fisher score (p = 0.01). Negative NBAL was associated with lower caloric intake (p < 0.001), higher body mass index (p < 0.001), aneurysm clipping (p = 0.03), and higher CRP:TTR ratio (p = 0.03). HAIs developed in 53 (23%) patients on mean PBD 8 ± 3. Older age (p = 0.002), higher Hunt Hess (p < 0.001), lower caloric intake (p = 0.001), and negative NBAL (p = 0.04) predicted time to first HAI. Poor outcome at 3 months was associated with higher Hunt Hess grade (p < 0.001), older age (p < 0.001), negative NBAL (p = 0.01), HAI (p = 0.03), higher CRP:TTR ratio (p = 0.04), higher body mass index (p = 0.03), and delayed cerebral ischemia (p = 0.04). Negative NBAL after SAH is influenced by inflammation and associated with an increased risk of HAI and poor outcome. Underfeeding and systemic inflammation are potential modifiable risk factors for negative NBAL and poor outcome after SAH.

Effect of 10% dietary protein intake on whole body protein kinetics in type 2 diabetic adults

Insulin resistance of protein metabolism occurs in obesity and type 2 diabetes (T2D). Hyperaminoacidemia during a simulated fed steady-state clamp compensates for this resistance. We tested whether decreasing protein intake affects the response to insulin with or without added amino acids, and if this response differs by sex. Protein intake was reduced from usual (15%) to 10% of an isoenergetic diet energy for 11 days, in T2D obese men (n = 8) and women (n = 10). Whole-body leucine kinetics (1-(13)C-leucine, surrogate for protein) were determined postabsorptive and during a hyperinsulinemic (∼600 pmol/L), hyperglycemic (8 mmol/L), isoaminoacidemic, followed by hyperaminoacidemic clamp and compared to those of T2D men on a 17% protein diet. Initial negative nitrogen balance approached equilibrium by day 10 but remained lower than with the 17% protein diet. During the hyperinsulinemic, isoaminoacidemic clamp, total leucine flux was less, with both lower endogenous rates of appearance (catabolism) and nonoxidative rates of disposal (synthesis), resulting in net balance at zero. With hyperaminoacidemia, net balance increased to 0.39 ± 0.09 μmol/kgLBM⋅min in men, significantly less than in men on 17% protein (0.98 ± 0.09, p < 0.01). There were no sex differences in clamp responses with 10% protein. After 11 days of 10% protein diet, there was a slight improvement in insulin sensitivity, but a blunted anabolic response to hyperaminoacidemia. Longer-term consequences of lesser anabolic efficiency at reduced protein intakes require study and may contribute to increased risk of sarcopenia in persons with T2D with aging.

Macronutrient Metabolism in Starvation and Stress.

In starvation and to a lesser extent in stress starvation, the loss of protein mass is spared as much as possible. This metabolic arrangement must have developed under the influence of evolutionary pressure in view of the importance of protein mass for function and longevity. Peripheral adipose tissue mass is only limiting when its mass is extremely small. Protein is the predominant precursor of glucose in (stress) starvation and glucose is an essential substrate for the synthesis and maintenance of cells and matrix and for the control of the redox state. To spare protein, glucose should be used efficiently only for those purposes that cannot be achieved by fat. It is suggested that this is achieved by limiting full glucose oxidation and increasing fatty acid and ketone body oxidation, which most likely can also largely cover energy needs of the central nervous system. In stress states, net negative nitrogen balance (catabolism) largely results from net losses of peripheral protein mass, predominantly muscles, whereas central organs (e.g. the liver), the immune system and wound healing are anabolic. A number of factors are responsible for a net negative nitrogen balance which may ultimately lead to death if stress persists. In stress, the amino acid mix derived from peripheral (predominantly muscle) tissues is modified in interplay with the liver and to a minor extent the kidney. This mix is different in nonstressed conditions, containing substantially increased amounts of the nonessential amino acids glutamine, alanine, glycine and (hydroxy)proline. Part of the amino acid skeletons released by muscles are substrates to produce glucose in the liver and kidney. Glucose and the amino acids produced especially serve as substrates for cell proliferation and matrix deposition. The catabolic processes in peripheral tissues cannot be countered completely by adequate nutritional support as long as stress persists. This metabolic arrangement dictates a nutritional mix containing liberal amounts of protein and carbohydrates and addition of lipids to cover energy requirements.

Nutritional strategy of early amino acid administration in very low birth weight infants.

Relative to a fetus of the same gestational age, very low birth weight (VLBW) infants are more likely to be underfed and to undergo growth restriction during their early hospital stay. The current trend towards "early and aggressive" nutritional strategies in VLBW infants aims to overcome the early nutritional deficiency and thereby boost postnatal catch-up growth, simultaneously improving long-term neurodevelopmental outcomes. Although the minimum starting amino acid (AA) dose to prevent negative nitrogen balance is well established, the upper limit and the rate of increase of early AA doses are controversial. Most randomized controlled trials show that early and high-dose (target, 3.5 to 4.9 g/kg/day) AA regimens, with or without high nonprotein calories, do not improve long-term growth and neurodevelopment. High-dose AA supplementation may lead to early metabolic disturbances and excessive or disproportionate plasma AA levels, particularly in infants of very low gestational age. Further large studies are needed to clarify the optimal strategy for early administration of parenteral AA doses in VLBW infants.

Odběr a bilance živin při různé intenzitě využívání trvalých travních porostů

In 2003–2005 it was solved the issue about the nutrient balance in the permanent grasslands of Research Institute for Cattle Breeding Rapotín. In trial it was used these types of utilization: 1. Intensive – 4 cuts per year (1st cut up to 15th May, every next after 45 days), 2. Medium intensive – 3 cuts per year (1st cut from 16th to 31st May, every next after 60 days), 3. Low intensive – 2 cuts per year (1st cut up to 15th June, 2nd after 90 days), 4. Extensive – 2 cuts per year (1st cut from 16th to 30th June, 2nd after 90 days). There were following variants of the fertilization: A – no fertilization, B – P:K 30:60 kg.ha – 1, C – N:P:K 90:30:60 kg.ha – 1, D – N:P:K 180:30:60 kg.ha – 1. There was the considerable reaction of the permanent grassland on the nutrient application. The highest value of the coefficient of the neutral efficiency was by the fertilization N:P:K 90:30:60 kg of the pure nutrients. By the most of the variants we have noticed the negative nitrogen balance. The negative balance of the phosphorous was marked only by the unfertilized variants. All variants of the permanent grassland utilization had the negative potassium balance. The utilization had the significant influence (P0.01) to all observed indicators. The year had the significant influence too. From the point of view of the rational plant nutrition and of the environment protection from the contamination (especially from the nitrates) it appears as the most advisable the medium intensive type of the utilization with nitrogen dose: N:P:K 90:30:60.

Henrik Kehlet, M.D., Ph.D., recipient of the 2014 Excellence in Research Award.

Henrik Kehlet, M.D., Ph.D., recipient of the 2014 Excellence in Research Award.

Recovery of nutritional metabolism after liver transplantation

ObjectivePerioperative nutritional assessment is critically important to reflect nutritional management because liver transplantation (LTx) often is undertaken in patients with poor nutritional status. The aim of this study was to evaluate nutritional status, including the non-protein respiratory quotient (npRQ), resting energy expenditure (REE), nitrogen balance, and blood biochemical parameters in patients before and after LTx. MethodsFourteen patients undergoing LTx and 10 healthy controls were enrolled in this study. The npRQ and REE were measured using indirect calorimetry before LTx and at 2, 3, and 4 wk after the procedure. Blood biochemistry and nitrogen balance calculated by 24-h urine collection were performed concurrently with indirect calorimetric measurement; the results were compared between the two groups. ResultsBefore LTx, npRQ was significantly lower and serum non-esterified fatty acid levels were significantly higher in the patients than in the controls. Furthermore, a negative nitrogen balance was observed in the patients. These, however, improved significantly at 4 wk after LTx. REE did not significantly increase compared with the preoperative values in recipients. Blood biochemistry showed gradually increasing levels of serum cholinesterase and albumin. These failed to reach to normal levels by 4 wk post-transplant. ConclusionsThe findings revealed that improvement of nutritional metabolism after LTx may require 4 wk. Additional nutritional strategies, therefore, may be needed to minimize catabolic state during the early post-transplant period. Adequate, individualized nutritional guidance before and after LTx should be performed in these patients.