Nutritional factors that can cause the patient to deteriorate:
(1) rapid weight loss
(2) poor nutritional intake (starvation)
(3) gastric bypass surgery
(4) malabsorption
(5) high protein diet
(6) short bowel syndrome
(7) parenteral nutrition with high nitrogen load
Systemic stress:
(1) gastrointestinal or internal bleeding
(2) significant infection (viral, bacterial, fungal) with generalized stress
(3) comorbid metabolic disorders (fatty acid oxidation defects, organic acidemia)
Trauma or surgery:
(1) major fracture
(2) major surgery or trauma
(3) postpartum state
(4) major organ transplant
Drug or toxin exposure:
(1) high dose or intravenous glucocorticoids
(2) chemotherapy, including cyclophosphamide
(3) valproic acid
(4) exposure to 5-pentanoic acid (Jamaican vomiting sickness)
Liver disease:
(1) cirrhosis with portal hypertension and shunting
(2) acute hepatitis or liver injury
