The liver is a complex organ with a wide array of functions. These functions affect almost every other system in the body. The liver maintains blood sugar levels, fat and protein balances, plays a crucial role in cleaning the blood, produces clotting factors, and makes proteins that are necessary for transporting hormones and fatty acids around the body. The liver also produces cholesterol, the building block for hormones such as testosterone, estrogen, and progesterone. Finally it is the liver that produces bile, an emulsifier for the fat that we ingest.

When the liver is not functioning well, both general and specific symptoms may arise. One of the general symptoms that appears when the liver is affected is fatigue,. Other general symptoms are abdominal discomfort, and swelling of the lower extremities. In addition, easy bruising, some neuropathies (due to high ammonia levels in the blood), and weight changes can be indications of a compromised liver. More specific liver symptoms may be jaundice (yellowing of the skin and eyes, and very dark urine) and oily and pale stools.

Illnesses that affect the liver are hepatitis (inflammation of the liver), fatty liver, cirrhosis, cancer, and gallstones. These broad categories reflect the change to the liver, as opposed to what is actually causing the symptoms or changes. The origins of these changes can be viral hepatitis, alcohol, toxic exposures, or medications. These infections and substances can damage the liver and may lead to changes that ultimately compromise its ability to function normally.

There are several laboratory tests used to monitor how the liver is working as well as to determine the cause of the problem. These tests include the following blood tests AST, ALT, GGT, alkaline phosphatase, bilirubin, and ammonia. Additionally, the liver can be visualized using , ultrasound and CT scan. Ultimately, a biopsy may also be necessary to determine changes in the liver. Some of these tests are run on a routine basis to monitor how the liver is managing, especially for people who are on medications that may damage the liver. For further information, please see the article on liver function tests in this issue.

Since the liver is the organ that cleans the blood, it is easily affected by what the body is exposed to. Antiretroviral medications can have a major impact on the health of the liver. For example, the protease inhibitor Norvir (RTV, or ritonavir) is often incorporated into drug regimens to "boost" levels of other medications by decreasing their metabolism. Norvir does this by slowing or shutting down the pathways in the liver that break down other medications, such as some other protease inhibitors, from the bloodstream. This is done to increase blood levels of the other medications. The effect of taking St. John's wort is another example of the interaction between the liver and medications. The herb, used to treat depression, increases the rate at which Crixivan (IDV, or indinavir) is broken down in the liver, making the medication less effective in fighting HIV.

Most substances -- whether medication, food, drink, or air -- have the potential to alter liver functions. When overloaded by clearing toxins, the liver has trouble keeping up with its other functions. It is important to understand that the liver has limitations. Yet, it has impressive abilities to adapt and regenerate, both of which are to our advantage. We can also be reassured that there are many things a person can do to support the liver.

By supporting the liver, we can increase detoxification of the blood and help metabolize foods for energy and hormone production, as well as encourage production of albumin and clotting factors. Supporting the liver has the potential to alter the breakdown of drugs such as non-nucleoside analogues, nucleoside analogues, protease inhibitors, and antibiotics, which may have beneficial or adverse effects. It is important to consult with practitioners knowledgeable in HIV/AIDS and supportive treatments for the liver. Monitoring of the liver, HIV and HCV viral loads, lymphocyte counts, symptoms, and sense of well being will help determine the effect that liver support is having. Improving liver function relieves the rest of the body from stress, thus increasing tolerance of medications and improving the overall health of body systems.

There are many ways to support the liver, and it does not always require a pill or supplement. A diet made up of mostly organic, whole, unprocessed foods, with an emphasis on vegetables, fruits, lean meats, and whole grains, provides foods rich in fiber and low in refined sugars. It is also important to minimize intake of caffeine and alcohol. (A note on alcohol and antiretroviral drugs: Don't mix these substances together. Both alcohol and antiretroviral drugs tax the liver; the combination is more than the liver can manage. When liver function tests show any increase in liver enzymes, it should be a strong deterrent from drinking alcohol.) It is difficult to go wrong with this foundation of nutrition.

A primary focus in protecting the liver is preventing damage caused by free radicals. Nutrients to facilitate this are vitamins C and E, beta-carotene and selenium. Yellow, orange, and red fruits and vegetables have a high content of vitamin C and betacarotene. Foods rich in vitamin E are oils like wheat germ and soybean oil. Meat is the primary source of selenium. Other types of food to incorporate into the diet are foods from the brassica family. These include broccoli, cauliflower and Brussels sprouts. These vegetables contain precursors needed for glutathione, a major contributor to the detoxification processes of the liver. Root vegetables, such as carrots and beets, are also nutritive foods for the liver.

Exercise can also be helpful for the liver. Movement as simple as deep breathing can improve blood circulation through the liver. Improved circulation removes wastes and allows nutrients to enter the liver. Contrast hydrotherapy is another way to increase blood flow through the liver. Contrast hydrotherapy is the use of hot and cold applications over the liver. Start with a hot towel (only as hot as it can be made with bare hands under the faucet) placed over the liver area (upper, right side of the abdomen) for three minutes. Then switch to a cold, moist towel for one minute. Use a towel that has been in the freezer if it can be tolerated -- if not, use cold water from the faucet; have several of these prepared. Alternate the hot and cold three times, ending with cold.

Another therapy to reduce liver inflammation is castor oil packs. Apply a small amount of castor oil over the liver area. Place a sheet of plastic wrap over the oil, followed by a towel. Over the towel, apply heat. This can be left in place for up to 45 minutes.

There are many supplements used to support the liver in metabolizing substances. Common liver supportive supplements are N-acetyl cysteine (NAC), glutathione (GSH), choline, methionine, carnitine, and antioxidants. NAC, the precursor to glutathione, is used to promote detoxification pathways. Choline (found in lecithin, egg yolks, and beans) and methionine are supplements that help to prevent deposition of fat into the liver. Carnitine can also be an important supplement, especially if a person has lipid abnormalities or body shape changes. Carnitine allows fats to be used as energy, thus preventing and alleviating fat deposition into the liver as well as other areas of the body.

Finally, there are liver herbs. A key herb is Silybum marianum, or milk thistle, an antioxidant with an affinity for the liver. It increases glutathione levels, resulting in improvement of the clearing of unwanted toxins in the blood. Milk thistle helps in the regeneration of liver tissue and decreases inflammation. Both the anti-inflammatory and the regeneration effects are important in preventing and repairing damage to the liver.

Another herb that is of great benefit to the liver is Cynara scolymus, or artichoke leaves. Like milk thistle, it is liver protective and restorative. Artichoke also has a cholesterol- and triglyceride-lowering effect. In addition, artichoke has a choleretic, or bile-producing, and bile moving effect on the liver. When bile lingers in the liver, it irritates the tissue, creating inflammation and decreasing the ability of the liver to carry out its function. Something to consider when eating artichokes (a fine way to reap the benefits of this medicinal) is to purchase and eat only organic artichokes. Since the leaves are where herbicides and pesticides are sprayed, and the leaves are what is eaten, it may do more harm than good to eat non-organic artichokes.

Licorice, or Glycyrrhiza glabra, is another powerful and useful herb for the liver (as well as many other systems of the body). This herb protects the liver from free radical damage. Not only does this herb affect the liver, but it may also enhance the immune system (increasing interferon, one of the body's ways to prevent viral infection of nearby cells). Licorice should not be used by people with high blood pressure or kidney failure, or who use digitalis medications.

This information may sound like the only way to have a healthy liver is to take the enjoyable things out of life, but each of us knows where our balance is. Be conscientious of what you take into your body when you drink, eat, breathe, and take your medications and supplements. Consider being thoughtful of what you ingest as an investment in your health and well being. Caring for your liver may include learning new ways of choosing and preparing food. It may mean incorporating exercise into your life. And yes, it may mean adding more pills to swallow each day. Whatever the changes you decide to make, you can make them with support. There are many services (such as cooking classes) and professionals (such as naturopaths and nutritionists) available to make these transitions easier.