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Fatigue and serum carnitine levels in chronic liver disease

SIRS, Fatigue is the most common and potentially most limiting symptom of liver disease, but strangely, is rarely the focus of study or research. Indeed, most studies of natural history and trials of therapy in liver disease do not measure, or even mention, fatigue. This shortcoming is particularly striking in chronic hepatitis C, where large numbers of trials of antiviral therapy have been published, but few have provided information on symptoms and whether they change with treatment. Fatigue is often mentioned as an ‘adverse event’ of treatment, and its frequency before starting and after stopping is not always given. The reasons for this are many: fatigue is nonspecific, multi-factorial, often mild, capable of fluctuating from week to week and difficult to measure objectively. Most importantly, the field of hepatology is yet to develop or accept a validated and reproducible instrument for assessing fatigue, and those that have been used have shown little correlation with disease activity (serum transaminase levels, histology activity scores) and stage (fibrosis scores short of cirrhosis). Anty et al. have taken on some of these issues, attempting to shed light on the nature of fatigue in liver disease. They report an association between fasting serum carnitine levels and the severity of fatigue, as assessed by a Fatigue Impact Scale questionnaire in 70 noncirrhotic patients with chronic hepatitis C. The association was mostly statistical, the dot-plots in figure 3 showing overlap of carnitine levels at different levels of fatigue and lack of homogeneity of the results (driven by the 5 or 6 ‘outliers’). Nevertheless, Anty et al. have taken on an important area in hepatology research with interesting results. Clearly, more investigation is needed into the frequency and nature of symptoms of liver disease, their clinical significance, pathogenesis and fluctuation with both specific and non-specific therapies.