{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T01:13:34Z","timestamp":1792113214063,"version":"4.4.0"},"reference-count":38,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2022,6,8]],"date-time":"2022-06-08T00:00:00Z","timestamp":1654646400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Background: The present study investigates the relationship between hypertransaminasemia and malnutrition on the basis of a very large number of patients. We assume that the level of transaminases not only reflects the extent of underlying liver cell damage but also provides information about the metabolic situation under conditions of energy deficiency. Methods: We present an observational study in two different samples. The first sample consists of 3755 patients (mean age 22.7 years, Range 12\u201373 years; mean BMI 15.4 kg\/m2, range 8.1\u201325.7) out of a total of 4212 patients with anorexia nervosa treated in the Roseneck Clinic within five years for whom a complete admission laboratory was available. The second sample was obtained from a special ward for medically at-risk patients with eating disorders. During the period in question, four hundred and ten patients with anorexia nervosa were treated. One hundred and forty-two female patients (mean age 26.4 years, Range 18\u201363 years; mean BMI 11.5 kg\/m2, range 8.4\u201313) had a BMI of thirteen or less and a complete data set was obtained at admission and weekly in the following four weeks after admission. Results: The increase in liver transaminases shows a very high correlation with weight in sample one (N = 3755). The analysis of variance shows highly significant (&lt;0.001) correlations with an F-value of 55 for GOT\/AST and 63 for GPT\/ALT. Nevertheless, the variance within the groups with the same BMI is quite high. With re-nutrition in sample two, GOT\/AST decreased on average from 71 U\/L to 26 U\/L (MANOVA F 10.7, p &lt; 0.001) and GPT\/ALT from 88 to 41 U\/L (F = 9.9, p &lt; 0.001) within four weeks. Discussion: Below a BMI of about 13, the nutritional status of the patients becomes so critical that the energy supply of the patient is increasingly dependent on the autophagy of the liver, which can be seen in the very strong increase in transaminases here. Refeeding leads very quickly to the normalisation of the transaminases and, thus, a stabilisation of the metabolism leading also to a decrease in autophagy.<\/jats:p>","DOI":"10.3390\/nu14122378","type":"journal-article","created":{"date-parts":[[2022,6,12]],"date-time":"2022-06-12T23:55:24Z","timestamp":1655078124000},"page":"2378","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":24,"title":["Liver Damage Is Related to the Degree of Being Underweight in Anorexia Nervosa and Improves Rapidly with Weight Gain"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2394-9935","authenticated-orcid":false,"given":"Ulrich","family":"Cuntz","sequence":"first","affiliation":[{"name":"Schoen Clinic Roseneck, Am Roseneck 6, 83209 Prien am Chiemsee, Germany"},{"name":"Forschungsprogramm f\u00fcr Psychotherapieevaluation im komplexen Therapiesetting, PMU Paracelsus Medical University Salzburg, 5020 Salzburg, Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0261-3145","authenticated-orcid":false,"given":"Ulrich","family":"Voderholzer","sequence":"additional","affiliation":[{"name":"Schoen Clinic Roseneck, Am Roseneck 6, 83209 Prien am Chiemsee, Germany"},{"name":"Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-Universit\u00e4t M\u00fcnchen (LMU), 80336 Munich, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,6,8]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1016\/1054-139X(94)90505-3","article-title":"Hypercarotenemia and transaminitis in female adolescents with eating disorders: A prospective, controlled study","volume":"15","author":"Sherman","year":"1994","journal-title":"J. Adolesc. Health Off. Publ. Soc. Adolesc. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"751","DOI":"10.1002\/eat.22162","article-title":"Severely elevated transaminases in an adolescent male with anorexia nervosa","volume":"46","author":"Smith","year":"2013","journal-title":"Int. J. Eat. Disord."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"486","DOI":"10.1007\/s11606-016-3879-8","article-title":"Expanding the differential diagnosis for transaminitis in patients with anorexia nervosa","volume":"32","author":"Nadelson","year":"2017","journal-title":"J. Gen. Intern. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1002\/(SICI)1098-108X(199611)20:3<325::AID-EAT13>3.0.CO;2-Z","article-title":"Abnormal liver enzymes in outpatients with eating disorders","volume":"20","author":"Mickley","year":"1996","journal-title":"Int. J. Eat. Disord."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"575","DOI":"10.2169\/internalmedicine.38.575","article-title":"Anorexia nervosa with severe liver dysfunction and subsequent critical complications","volume":"38","author":"Furuta","year":"1999","journal-title":"Intern. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1959","DOI":"10.1023\/A:1005642601144","article-title":"Marked transaminase elevation in anorexia nervosa","volume":"45","author":"Kozaiwa","year":"2000","journal-title":"Dig. Dis. Sci."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1002\/eat.20002","article-title":"Acute liver damage in anorexia nervosa","volume":"36","author":"Lion","year":"2004","journal-title":"Int. J. Eat. Disord."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"572","DOI":"10.1016\/j.nut.2006.01.003","article-title":"Severe acute liver damage in anorexia nervosa: Two case reports","volume":"22","author":"Alfano","year":"2006","journal-title":"Nutrition"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1016\/j.jpeds.2008.01.036","article-title":"Prevalence and predictors of abnormal liver enzymes in young women with anorexia nervosa","volume":"153","author":"Fong","year":"2008","journal-title":"J. Pediatr."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"840","DOI":"10.1053\/j.gastro.2008.05.055","article-title":"Acute liver cell damage in patients with anorexia nervosa: A possible role of starvation-induced hepatocyte autophagy","volume":"135","author":"Rautou","year":"2008","journal-title":"Gastroenterology"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1447","DOI":"10.2169\/internalmedicine.47.0824","article-title":"Hepatocellular injuries observed in patients with an eating disorder prior to nutritional treatment","volume":"47","author":"Tsukamoto","year":"2008","journal-title":"Intern. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"770","DOI":"10.1002\/eat.20775","article-title":"Recurrent acute hepatic dysfunction in severe anorexia nervosa","volume":"43","author":"Dowman","year":"2010","journal-title":"Int. J. Eat. Disord."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e294","DOI":"10.1007\/BF03325312","article-title":"Brief elevation of hepatic enzymes due to liver ischemia in anorexia nervosa","volume":"15","author":"Giordano","year":"2010","journal-title":"Eat. Weight Disord. EWD"},{"key":"ref_14","first-page":"1378","article-title":"High level increase in liver enzymes and severe thrombocytopenia in a male case of anorexia nervosa","volume":"16","author":"Karahmadi","year":"2011","journal-title":"J. Res. Med. Sci. Off. J. Isfahan Univ. Med. Sci."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1002\/eat.22073","article-title":"Elevation of liver function tests in severe anorexia nervosa","volume":"46","author":"Harris","year":"2013","journal-title":"Int. J. Eat. Disord."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"205","DOI":"10.5152\/tjg.2014.2531","article-title":"Acute liver damage and anorexia nervosa: A case report","volume":"25","author":"Bridet","year":"2014","journal-title":"Turk. J. Gastroenterol. Off. J. Turk. Soc. Gastroenterol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"473","DOI":"10.1097\/MEG.0000000000000030","article-title":"Reversible severe hepatitis in anorexia nervosa: A case report and overview","volume":"26","author":"Ramsoekh","year":"2014","journal-title":"Eur. J. Gastroenterol. Hepatol."},{"key":"ref_18","first-page":"E26-31","article-title":"Clinical manifestations of liver injury in patients with anorexia nervosa","volume":"44","author":"Tomita","year":"2014","journal-title":"Hepatol. Res. Off. J. Jpn. Soc. Hepatol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1016\/j.jpeds.2014.10.048","article-title":"Associations of elevated liver enzymes among hospitalized adolescents with anorexia nervosa","volume":"166","author":"Nagata","year":"2015","journal-title":"J. Pediatr."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1002\/eat.22436","article-title":"Liver dysfunction in patients with severe anorexia nervosa","volume":"49","author":"Rosen","year":"2016","journal-title":"Int. J. Eat. Disord."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"488","DOI":"10.11622\/smedj.2015132","article-title":"Prevalence of abnormal liver function tests and comorbid psychiatric disorders among patients with anorexia nervosa and eating disorders not otherwise specified in the anorexia nervosa DSM-IV criteria","volume":"56","author":"Goh","year":"2015","journal-title":"Singap. Med. J."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"563","DOI":"10.2169\/naika.78.563","article-title":"Two cases of anorexia nervosa associated with grossly abnormal liver function tests","volume":"78","author":"Yamagata","year":"1989","journal-title":"Nihon Naika Gakkai Zasshi. J. Jpn. Soc. Intern. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"307","DOI":"10.1186\/1752-1947-4-307","article-title":"Elevated transaminases as a predictor of coma in a patient with anorexia nervosa: A case report and review of the literature","volume":"4","author":"Yoshida","year":"2010","journal-title":"J. Med. Case Rep."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1016\/j.clnu.2012.08.020","article-title":"Hypertransaminasemia in severely malnourished adult anorexia nervosa patients: Risk factors and evolution under enteral nutrition","volume":"32","author":"Hanachi","year":"2013","journal-title":"Clin. Nutr."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"701064","DOI":"10.1155\/2014\/701064","article-title":"Liver autophagy in anorexia nervosa and acute liver injury","volume":"2014","author":"Kheloufi","year":"2014","journal-title":"BioMed Res. Int."},{"key":"ref_26","first-page":"749169","article-title":"Severe Starvation-Induced Hepatocyte Autophagy as a Cause of Acute Liver Injury in Anorexia Nervosa: A Case Report","volume":"2013","author":"Restellini","year":"2013","journal-title":"Case Rep. Hepatol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"437","DOI":"10.1083\/jcb.33.2.437","article-title":"Influence of glucagon, an inducer of cellular autophagy, on some physical properties of rat liver lysosomes","volume":"33","author":"Deter","year":"1967","journal-title":"J. Cell Biol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1002\/path.2697","article-title":"Autophagy: Cellular and molecular mechanisms","volume":"221","author":"Glick","year":"2010","journal-title":"J. Pathol."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Ichimiya, T., Yamakawa, T., Hirano, T., Yokoyama, Y., Hayashi, Y., Hirayama, D., Wagatsuma, K., Itoi, T., and Nakase, H. (2020). Autophagy and Autophagy-Related Diseases: A Review. Int. J. Mol. Sci., 21.","DOI":"10.3390\/ijms21238974"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1344","DOI":"10.1126\/science.1193497","article-title":"Autophagy and metabolism","volume":"330","author":"Rabinowitz","year":"2010","journal-title":"Sci.)"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"18944","DOI":"10.1038\/srep18944","article-title":"Mammalian autophagy is essential for hepatic and renal ketogenesis during starvation","volume":"6","author":"Takagi","year":"2016","journal-title":"Sci. Rep."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"709","DOI":"10.1080\/15548627.2016.1151597","article-title":"Emerging role of mammalian autophagy in ketogenesis to overcome starvation","volume":"12","author":"Takagi","year":"2016","journal-title":"Autophagy"},{"key":"ref_33","first-page":"1","article-title":"CDC growth charts: United States","volume":"314","author":"Kuczmarski","year":"2000","journal-title":"Adv Data"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"178","DOI":"10.1002\/erv.2877","article-title":"Rapid renutrition improves health status in severely malnourished inpatients with AN-score-based evaluation of a high caloric refeeding protocol in severely malnourished inpatients with anorexia nervosa in an intermediate care unit","volume":"30","author":"Cuntz","year":"2022","journal-title":"Eur. Eat. Disord. Rev. J. Eat. Disord. Assoc."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Koerner, T., Haas, V., Heese, J., Karacic, M., Ngo, E., Correll, C.U., Voderholzer, U., and Cuntz, U. (2020). Outcomes of an Accelerated Inpatient Refeeding Protocol in 103 Extremely Underweight Adults with Anorexia Nervosa at a Specialized Clinic in Prien, Germany. J. Clin. Med., 9.","DOI":"10.3390\/jcm9051535"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"406","DOI":"10.1007\/s11920-012-0282-y","article-title":"Epidemiology of eating disorders: Incidence, prevalence and mortality rates","volume":"14","author":"Smink","year":"2012","journal-title":"Curr. Psychiatry Rep."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1101","DOI":"10.1016\/j.psychres.2013.07.042","article-title":"Mortality in eating disorders: A follow-up study of adult eating disorder patients treated in tertiary care, 1995\u20132010","volume":"210","author":"Suokas","year":"2013","journal-title":"Psychiatry Res."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1002\/eat.22501","article-title":"Mortality in eating disorders\u2014Results of a large prospective clinical longitudinal study","volume":"49","author":"Fichter","year":"2016","journal-title":"Int. J. Eat. Disord."}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/14\/12\/2378\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T23:26:26Z","timestamp":1760138786000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/14\/12\/2378"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,6,8]]},"references-count":38,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2022,6]]}},"alternative-id":["nu14122378"],"URL":"https:\/\/doi.org\/10.3390\/nu14122378","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,6,8]]}}}