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Cap itolu l 6
Metabolismul glucidic
n cazul lipsei de aport alimentar, ficatul contribuie la homeostazia glucozei
prin glicogenoliz i gluconeogenez ca rspuns la hipoinsulinemie i
hiperglucagonemie. Meninerea nivelurilor normale ale glucozei sanguine prin
gluconeogenez este n direct relaie cu catabolismul proteinelor musculare care
asigur aminoacizii precursori necesari, n special alanina. n mod complementar,
postprandial, ficatul direcioneaz alanina i aminoacizii cu lan ramificat ctre
esuturile periferice, unde sunt apoi ncorporai n proteinele musculare. Se
formeaz asftel, o cale de transformare bidirecional glucoz-alanin, care este
modulat de schimbrile ambientale i de hormonii menionai mai sus (3,4). Dei
s-a presupus c sinteza glicogenului i a acizilor grai n stadiul postprandial
pornete de la conversia direct a glucozei, exist date care sugereaz c, de fapt,
aceste ci sunt indirecte, cu produse derivate din metaboliii glucozei, coninnd
trei atomi de carbon, sau din ali compui gluconeogenetici, cum ar fi lactatul,
fructoza i alanina (5). Anomaliile homeostaziei glucozei n ciroz sunt redate n
tabelul nr. 1. Cel mai frecvent se observ hiperglicemia i intolerana la glucoz (6).
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cei mai muli dintre aceti pacieni (10,22). Diabetul se manifest clinic pe msur
ce funcia hepatic se deterioreaz, astfel c diabetul hepatogen poate fi
considerat drept un indicator al bolii hepatice avansate (23).
n dezvoltarea diabetului hepatogen un rol important l deine etiologia
afectrii cronice a ficatului, mai ales alcoolul, virusul hepatitic C (VHC),
hemocromatoza i steatohepatita non-alcoolic (NASH) (24).
Alcoolul
Alcoolul influeneaz metabolismul glucozei att la pacienii diabetici ct i
la cei non-diabetici. Deoarece alcoolul inhib att gluconeogeneza ct i
glicogenoliza, ingestia acut fr alimente poate provoca hipoglicemie, mai ales n
cazurile cu rezerve reduse de glicogen sau n combinaie cu un sulfonilureic (25).
Consumat cu o mas de carbohidrai, alcoolul poate duce iniial la creterea
glicemiei i stimula rspuns insulinic la pacienii cu diabet tip 2. n funcie de tipul
de carbohidrai consumai, aceasta poate fi urmat de hipoglicemie reactiv (25).
Consumul moderat de alcool este asociat cu reducerea riscului aterosclerotic. n
cazul folosirii moderate, riscul dezechilibrului glicemic, ponderal i al tensiunii
arteriale este limitat (25). n schimb, consumul excesiv nu determin doar
pierderea controlului metabolic, dar i creterea riscului de diabet prin afectarea
cronic a pancreasului i lezarea celulelor beta insulare (26).
Hemocromatoza
Hemocromatoza ereditar este caracterizat de acumularea de fier n
organism ca urmare a unei alterri a metabolismului acestui metal, caracterizat
prin absorbia intestinal crescut, produs de o mutaie a genei HFE (39,40).
ncrcarea cu fier poate fi i secundar, ntlnit n anemia aplastic, deficitul de
piruvat kinaz, anemia sideroblastic, talasemia major, suprancrcarea
parenteral de fier, transfuzii repetate, boal hepatic alcoolic, hepatita viral B,
C, steatohepatita non-alcoolic (NASH), porfiria cutanea tarda, unt portocav.
n hemocromatoza ereditar, hemosiderina se poate acumula la nivelul
ficatului, pancreasului, miocardului, glandelor suprarenale, tiroidei, paratiroidelor,
n articulaii i n piele. n pancreas, concentrarea fierului are loc predominant la
nivelul acinilor responsabili de secreia exocrin. Totui se poate observa i
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Steatohepatita non-alcoolic
Steatohepatita non-alcoolic (NASH) este o manifestare sever a bolii
ficatului gras non-alcoolic-NAFLD (nonalcoholic fatty liver disease). NAFLD
cuprinde un spectru de boli hepatice cronice, de la steatoza benign (acumularea
gras) (42) pn la ciroza avansat i cancer. Dei majoritatea pacienilor cu NAFLD
au o evoluie benign, dezvoltarea steatohepatitei cu necroinflamaie i fibroz
progresiv, crete riscul dezvoltrii cirozei i complicaiilor ei (43). Dintre pacienii
cu NASH aproximativ 28% fac ciroz ntr-o perioad de urmrire de 8 ani (44).
Factori demografici, antropometrici, clinici i de laborator sunt asociai cu
NAFLD i cu modificrile serioase histologice ale bolii. Dintre aceti factori cea mai
reprezentativ asociere a NAFLD cu fibroza include vrsta avansat, rezistena la
insulin/diabet, obezitatea i hipertensiunea arterial, ns potenialul acestor
factori de a prezice severitatea bolii i evoluia ei este limitat (45).
Enzimele serice hepatice sunt folosite de rutin pentru screening-ul bolii
cronice hepatice, inclusiv al steatohepatitei non-alcoolice. Dei alanin-
aminotransferaza (ALT) sau aspartat-aminotransferaza (AST) tind s fie mai mari la
pacienii cu NASH comparativ cu steatoza, aceti markeri nu au suficient
specificitate i sensibilitate pentru un diagnostic sigur de NASH. Sensibilitatea
creterii ALT pentru diagnosticul NASH este de aproximativ 40-50%, iar
specificitatea, aproximativ 50% (46). ntr-o serie de 354 de pacieni cu citoliz,
valoarea predictiv pozitiv a transaminazelor n diagnosticul NASH a fost de doar
34% (47). ntr-un alt studiu pe un grup de femei supraponderale, sensibilitatea ALT
n diagnosticul NASH a fost 42% (48). Aceste descoperiri nu sunt surprinztoare
avnd n vedere c unii pacieni cu NASH, muli chiar cu fibroz, au adesea
transaminaze normale (49).
Dei unele studii arat o legatur ntre ras i prevalena NAFLD i NASH,
rasa nu poate fi luat drept predictor al fibrozei avansate n NAFLD (50).
Similar cu celelalte boli hepatice cronice, vrsta >45 de ani este predictiv
pentru fibroz i ciroz n NAFLD (45). Dezvoltarea sindromului metabolic n
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Tratament
Tratamentul diabetului la pacienii cu ciroz hepatic prezint cteva
particulariti (16,17):
aproape jumtate dintre pacieni sunt malnutrii;
cnd diabetul este diagnosticat clinic, pacienii prezint boal hepatic
avansat;
cei mai muli ageni hipoglicemiani orali sunt metabolizai n ficat;
pacienii prezint episoade frecvente de hipoglicemie (16,17).
Pacienii asimptomatici, cu intoleran uoar la glucoz nu necesit alt
tratament n afara evitrii excesului de carbohidrai, ntruct n acest stadiu
rezistena la insulin este factorul dominant. Totui, aceste msuri terapeutice ar
putea fi compromise de dietele foarte restrictive, ntruct ar putea agrava
malnutriia la unii pacieni. Pe de alt parte, exerciiul fizic, care mbuntete
rezistena la insulin, ar putea s nu fie o msur corespunztoare la pacienii cu
boal hepatic activ (66).
Biguanidele, care reduc rezistena la insulin, administrate per oral ar
putea fi utile. Metforminul este o biguanid care este contraindicat la pacienii cu
insuficien hepatic avansat i la pacienii care continu s consume alcool
datorit riscului crescut de acidoz lactic (67).
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Hipoglicemia
Episoadele de hipoglicemie sunt rare la pacienii cu ciroz non-alcoolic, cu
excepia cazurilor de insuficien hepatic sever, dar acestea sunt importante la
alcoolici, recipienii de transplant hepatic, precum i la pacienii cu insuficien
hepatic acut i carcinom hepatocelular. Nerecunoaterea i, n consecin,
netratarea episoadelor de hipoglicemie pot conduce la neuroglicopenie i
demen cronic ireversibil (53).
Alcoolul inhib gluconeogeneza, favoriznd apariia hipoglicemiei care
poate fi de patru tipuri (4):
hipoglicemie matinal dup perioada de repaus alimentar nocturn,
hipoglicemie reactiv dup consumul acut de alcool,
hipoglicemie cu un aport alimentar sczut,
hipoglicemia indus de medicamente (de exemplu, propranolol,
antidiabetice orale, insulina) care poate fi exacerbat de aportul
alimentar sczut (17,54).
Toate aceste tipuri de hipoglicemie pot fi prevenite prin abstinen.
Hipoglicemia la pacienii cu insuficien hepatic acut este determinat de
pierderea aportului metabolic major al ficatului n glicogenoliz i gluconeogenez.
Ea poate fi tratat prin suplimentarea adecvat de glucoz fie oral, fie intravenos,
n funcie de necesiti.
La pacienii cu hepatocarcinom hipoglicemia poate aparea att timpuriu
ct i n stadiile preterminale de evoluie ale bolii. Hipoglicemia evideniat
timpuriu n evoluia bolii apare la pacienii cu tumori bine difereniate i este
asociat cu dou deficite enzimatice (glucozo-6-fosfataza i fosforilaza), ceea ce va
determina alterarea gluconeogenezei i a glicogenolizei (73). Hipoglicemia n
stadiul preterminal/avansat apare ca o consecin a cererii crescute a tumorii
pentru glucoz, cuplat cu scderea aportului oral datorat denutriiei i sintezei
hepatice insuficiente de glucoz. Tumora are cretere rapid, apetitul este
diminuat, masele musculare se topesc i astenia fizic e marcat (73). Dac excizia
chirurgical a formaiunii tumorale nu este posibil, se poate ca hipoglicemia s fie
destul de greu de tratat. O posibil form de tratament ar putea fi reprezentat de
administrarea continu de glucoz, fie pe sond nazo-gastric, fie prin
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Bolile tiroidiene
Alterrile funciei tiroidiene pot conduce la disfuncii hepatice, dar i
invers, afeciunile hepatice pot avea efecte asupra metabolismului hormonilor
tiroidieni. A fost notat o asociere ntre hepatita cronic activ i ciroza biliar
primitiv att cu hipotiroidismul autoimun, ct i cu antecedentele de
tireotoxicoz, dar studii prospective atent conduse, care s foloseasc i martori i
s urmreasc tirotropina seric (TSH) i hormonul eliberator de tirotropin (TRH),
nu sunt disponibile dect n asociere cu hepatita cronic activ (4). Numeroase
studii au artat o inciden crescut a titrului mare de autoanticorpi antitiroidieni
la pacienii cu boli hepatice autoimune (75-76). Este notat, de asemenea, i o
asociere rar ntre colangita sclerozant i tiroidita Riedel (77).
Testele funciei tiroidiene continu s provoace interes i controverse la
pacienii cu boli hepatice cronice. Principalul hormon tiroidian este
tetraiodotironina (tiroxina, T4) care se comport ca un prohormon prin conversia
periferic (deiodare) n triiodotironin (T3). Exist date care evideniaz o
conversie sczut a tiroxinei (T4) n T3 la pacienii cirotici, precum i sinteza unui
hormon denumit revers T3, inactiv fiziologic (78,79).
O alt problem major este proteina plasmatic de legare a hormonului
tiroidian. n circumstane normale, T3 i T4 sunt legate n plasm de globulina de
legare tiroidian (75%), de prealbumina de legare a tiroxinei (15%) i de albumin
(10%). La pacienii cu ciroz biliar primitiv, cu hepatit cronic activ i cu
hepatit viral, proteinele serice de legare a hormonilor tiroidieni, determinate
prin raportul de legare a resinelor de T3, cresc. Aceasta determin o uoar
cretere a concentraiilor serice totale de T3 i T4, dar cu concentraii reduse ale
fraciilor libere T3 i T4, biologic active, astfel c, dac se efectueaz doar
determinrile standard ale nivelurilor serice de T3 total i T4 total, hipotiroidismul
ar putea s nu fie evident biochimic la aceti pacieni. Prin contrast, pacienii cu
boal hepatic alcoolic au un nivel redus al proteinelor serice de legare a
hormonilor tiroidieni. De aceea, la pacienii cu boal hepatic cronic,
hipotiroidismul este cel mai bine apreciat prin concentraia seric a TSH: mai mult
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Sindromul pseudo-Cushing
Ocazional, pacienii cu ciroz alcoolic prezint semne de sindrom Cushing
florid, n mod deosebit facies pletoric, obezitate troncular, piele subire i
fragilitate capilar. ntr-un studiu recent, patru pacieni alcoolici, cu boal hepatic
minim sau absent, ce prezentau semne de sindrom Cushing, au fost descoperii
a avea o cretere a concentraiilor plasmatice de cortizol ntre 9 a.m. i miezul
nopii, o cretere a excreiei urinare pe 24 ore a cortizolului liber urinar, precum i
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Hipoadrenalismul
Insuficiena hepatic se aseamn ntr-o mare msur ocului septic,
amndou fiind caracterizate de prezena insuficienei circulatorii, hipotensiune
arterial, scderea rezistenei vasculare, cu consecine asupra funciei
suprarenalelor. Insuficiena suprarenalian asociaz instabilitate hemodinamic i
mortalitate ridicat, corelate cu severitatea bolii hepatice. 70% din cortizolul
plasmatic este legat de CBG (cortisol-binding globulin), 20% legat de albumin i
10% cortizol liber biologic activ. n condiiile insuficienei hepatice, cnd albumina
i CBG scad, cortizolul total poate fi sczut, dei fraciunea liber poate fi normal
sau chiar crescut (111).
Afectarea osoas
Pierderea rezistenei osoase, ce caracterizeaz osteoporoza, duce la
fracturi pe os patologic. Prevalena fracturilor la pacienii cu ciroz biliar primitiv
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este ntre 2-20%, iar la cei cu insuficien hepatic n stadiul pretransplant hepatic
este de aproximativ 22% (112). Mecanismul apariiei osteoporozei n ciroza biliar
primitiv nu a fost complet elucidat, deoarece unele studii susin creterea
resorbiei osoase, n timp ce altele sugereaz scderea osteogenezei (113).
Reducerea grosimii peretelului osului trabecular i creterea turnover-ului
sunt proporionale cu severitatea disfunciei hepatice i a colestazei (114).
Deficienele de calciu i de vitamin D, ce duc la hiperparatiroidism secundar, au
fost propuse ca fiind cauza turnoverului osos crescut. De asemenea,
osteoprotegerina, un membru al familiei receptorului pentru factorul de necroz
tumoral (TNF), care inhib diferenierea osteoclastelor, poate contribui la apariia
osteoporozei n ciroza biliar primitiv, deoarece scderea funciei hepatice poate
duce la reducerea produciei de osteoprotegerin i la creterea resorbiei
osteoclast mediate. Deocamdat rolul osteoprotegerinei rmne speculativ, mai
ales c s-au constatat i niveluri crescute n ciroza biliar primitiv, nelegate de
osteoporoz (115).
Complicaiile datorate colestazei cronice includ astenia fizic, pruritul,
steatoreea, deficitul vitaminelor liposolubile (A, D, E, K), i boala metabolic
osoas. Deficitul nutriional apare datorit scderii absorbiei vitaminelor
liposolubile, ca rezultat al reducerii concentraiei intestinale a acizilor biliari
conjugai. Boala metabolic osoas, numit i osteodistrofie hepatic, se poate
evidenia prin densitometria mineral osoas a coloanei lombare. La pacienii cu
osteopenie trebuie suplimentat aportul zilnic de calciu i de vitamin D, iar la cei
cu osteoporoz se adaug terapia cu bifosfonai (116).
Momentan nu exist suficiente dovezi care s susin eficiena
tratamentului cortizonic la pacienii cu ciroz biliar primitiv, iar atunci cnd acest
tratament este administrat, crete riscul osteoporozei induse de tratamentul cu
glucocorticoizi i al tasrilor vertebrale (29). Consumul de alcool ar trebui oprit,
tratamentul cu cortizon redus la doze minime, iar dieta ar trebui adaptat cu
supliment de calciu i cu vitamin D (26,117). De asemenea, trebuie evitat
imobilizarea prelungit.
Hipercalcemia, probabil datorat unei secreii tumorale de hormon
polipeptidic paratiroid-like, apare la unii pacieni cu hepatocarcinom. Alte anomalii
biochimice notate la aceti pacieni sunt: hipofosfatemie, hiperfosfaturie, precum
i o excreie urinar crescut de hidroxiprolin (118).
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Metabolismul sodiului
Retenia de sodiu este un factor n dezvoltarea ascitei datorat cirozei. Ali
factori majori sunt: hipoalbuminemia i hipertensiunea portal. Retenia de sodiu
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Hormonul de cretere
La unii copii cu boal hepatic cronic, ntrzierea de cretere este legat
mai mult de statusul de boal cronic, dect de existena unei deficiene a
hormonului de cretere. Creterea poate fi agravat la copii de tratamentul cu
cortizon, motiv pentru care un astfel de tratament ar trebui evitat sau s li se
administreze doze ct mai mici, cel puin n perioada de pubertate.
Concentraii crescute ale hormonului de cretere, att nivelul bazal ct i
cel stimulat de administrarea de hormon eliberator tireotrop, au fost descoperite
la pacienii cu ciroz alcoolic (132). Dac va fi confirmat, aceast cretere ar
putea fi un alt factor care s contribuie la patogeneza toleranei sczute la glucoz
i a dezvoltrii diabetului la aceti pacieni. Boala hepatic aprut n copilrie
afecteaz creterea, iar reducerea aportului de alimente, malabsorbia vitaminelor
liposolubile i a oligoelementelor contribuie la retardul creterii (133-137).
Copii au rezisten la GH (growth hormone), nivele sczute de IGF (insulin
like growth factor) i IGFBP3 (insulin-like growth factor binding protein 3) i
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secreie crescut de GH, i de IGFBP1 (insulin-like growth factor binding protein 1),
dar secreie redus de IGF2 (insulin-like growth factor 2).
Un IGF sczut indic sinteza sczut hepatic i expresia redus a
receptorului de GH ca n malnutriie (138). Posttransplant hepatic se
mbuntete creterea (135, 139-141), iar administrarea de glucocorticoizi poate
avea un rol n retardul creterii (135, 141). Valorile GH/IGF1 sunt n limite
normale, dar IGF liber este redus - nivelul de IGFBP3 este crescut.
Tratamentul cu GH exogen stimuleaz creterea i crete nlimea medie
cu 0,3- 0,6 uniti (Deviaie Standard) dup 1 an de tratament (142 145).
Eritropoietina
Dezvoltarea eritrocitozei, cu creterea hemoglobinei, a numrului de celule
roii, precum i a masei eritrocitare, n asociere cu un numr normal de
trombocite i leucocite la un pacient cu ciroz, de obicei precede dezvoltarea
hepatocarcinomului. Sindromul apare uneori i la pacienii non-cirotici.
Carcinoamele hepatocelulare reprezint a doua cauz de eritrocitoz dup
carcinoamele renale. Cercetarea radioimunologic a eritropoietinei este dificil de
efectuat, dar cea mai probabil explicaie a eritrocitozei este sinteza tumoral
inadecvat a acestui polipeptid.
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Concluzii
Patologia endocrin la pacienii cu boal hepatic cronic poate pune
probleme de diagnostic i tratament. Modificrile endocrine care apar la un bolnav
hepatic sunt polimorfe, fiind imposibil de conturat un model specific de tulburare
endocrin asociat hepatopatiei, acestea depinznd att de susceptibilitatea
individual, ct i de etiologia i evoluia bolii hepatice.
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