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Objectives
• Listspecificpointstokeepinmindwhenassessingthenutritionalstatusofpatientswithadvancedliverdisease.• Describethemanagementandnutritionalcarefornonalcoholicfattyliverdisease(NAFLD).• Describethenutrition-relatedproblemswithcirrhosisandlivertransplantation.• Describemedicalcomplicationsandnutritionalimplicationsofadvancedliverdisease.
NutritionAssessmentofAdvancedLiverDiseasePatients• FluidoverloadinterfereswithaccurateBMIandweight.• Albumin,prealbuminandtransferrindatacanbemisleadingduetoedema.• Anthropometricmeasurementscanbemisleadinginthepresenceofedema.• HandgripstrengthoruseofaBioelectricalImpedanceAnalysis(BIA)iscorrelatedwithbetteroutcomes.• Evaluationofrecentoralintakeremainsoneofthemostvaluablecomponentsofnutritionassessment.
NonalcoholicFattyLiverDisease(NAFLD)
•Mostcommoncauseofadvancedliverdisease.•Riskfactors:obesity,metabolicsyndrome,insulinresistance.•Nonalcoholicsteatohepatitis(NASH)
ManagementofNAFLD
• Lifestylemodifications– dietandexercise.• Surgicalweightlossinterventions– gastricbypass,gastricsleeveorbanding.• DiabetesmedicationsDiabetesMedicationsUsedtoTreatNonalcoholicFattyLiverDisease(NAFLD)
Source:Dataarefromreference3.
TypeofMedication Comments AdverseEffectsThiazolidinediones • MoststudiedtypeofdiabetesmedicationusedforNAFLD
• ShowbiochemicalandhistologicalbenefitinNAFLD• Weightgain• Decreasedbonemineraldensity• Increasedtriglycerides• Increasedratesofcardiovascularevents• Complicationsandexacerbationofcongestiveheart
failureMetformin • Biochemical,butnohistologicalbenefitasmonotherapy
• Cannotuseifcreatinine>1.5mg/dL• Diarrhea• Lacticacidosis
Incretinmimetics • Studiesongoing,butnoprovenhistologicalbenefit • Nausea• Delayedgastricemptying
NutritionalCareofNAFLD
• Saturatedfatlimitedtolessthan10%oftotalcalories.• Replacecarbohydratesandsaturatedfatswithmonounsaturatedfats.• Omega-3fattyacidsversesOmega-6fattyacids.• Limitrefinedsugarsandsugar-sweetenedbeverages(concentratedsweets).•Moderateamountsofleanprotein(animalandplant-basedprotein).• VitaminE– 400-800IU.
CirrhosisandLiverTransplantation–Malnutrition
• 20-80%ofpatientswithcirrhosisexperiencemalnutrition.• Nauseaandearlysatiety• Hypermetabolicstate• Reducedglucosestorage(inalcohol-inducedcirrhosis)• Insufficientintakeofproteinandenergy
• 53%ofpatientswaitingforlivertransplantationaremalnourished.
CirrhosisandLiverTransplantation– VitaminandMineralDeficiencies
MicronutrientDeficienciesAssociatedwithCirrhosisPotentialDeficiency Notes
Zinc • Replacementmaybehelpfulinmanaginghepaticencephalopathy.
Selenium
Magnesium
Water-solublevitamins(Bcomplex,VitaminC,thiamin)
• Deficiencyisparticularlycommoninalcoholicliverdisease.
Fat-solublevitamins • Deficiencyoccursparticularlyincholestaticliverdiseasesuchasprimarybiliarycirrhosis.
VitaminA(retinol) • Deficiencyisariskfactorforhepatocellularcarcinomaandfulminanthepaticfailure(ie,itocellhyperplasia).
VitaminD • Deficiencyoccursintwo-thirdsofpatientswithcirrhosisand96%ofpatientsawaitinglivertransplant.
VitaminE • Deficiencyoccursparticularlyincholestaticandalcoholicliverdisease.
VitaminK
CirrhosisandLiverTransplantation–Osteoporosis• 12-55%prevalenceinpatientswithcirrhosis• Riskfactors:
• VitaminKdeficiency• VitaminDdeficiency• Excessalcoholintake• Reducedserumtestosteronelevels• Corticosteroids
• 15-27%prevalenceafterlivertransplantation• Noncirrhoticbiliarydiseaseandprimarybiliarycirrhosis,hemochromatosisandexcessivealcoholintakeintheabsenceofcirrhosis.
CirrhosisandLiverTransplantation–Osteoporosis(cont.)• Treatment:• Onegramofcalciumplus800IUvitaminD(plusemphasisonfoodscontainingcalciumandvitaminD)• Bisphosphanates• Physicalactivity• VitaminK(ifdeficient)• Second-linetreatments– hormonereplacementtherapy• Biannualbonedensitytests,regardlessofwhetherpatientistreatedforosteoporosis
CirrhosisandLiverTransplantation– OtherNutrition-RelatedProblemsforCirrhosisPatients
• Edemaandascites– limitsodiumto2gm/day.
• Hypoglycemia– consumesmallfrequentmealsincludingabedtime/eveningsnack,whichincludesbothcarbohydrateandprotein.Oralliquidnutritionalsupplementsasneeded.
• Septicemia– avoidrawseafood(molluscanshellfish,oysters).
MedicalComplicationsandNutritionalImplicationsofAdvancedLiverDisease
• Pancreaticinsufficiency– MCToil,saffloweroil,fat-soluble(D,E,A,andK)vitaminsupplementsandpancreaticenzymes.
• HepaticEncephalopathy– providedadequatemedications(lactuloseorrifaximin),andoptimizeproteintoasmuchasthepatientisabletotolerate.• 0.8gmprotein/kgbodyweight.• Branched-chainedaminoacids(BCAAs,ie.,leucine,isoleucineandvaline)maybebeneficial.
MedicalComplicationsandNutritionalImplicationsofAdvancedLiverDisease(cont.)
• AlcoholicHepatitis– generaldailyguidelinesare1.2-1.5gmprotein/kgofbodyweightand35-40kcal/kgofbodyweight.• AcuteLiverFailure– catabolicstatewithaheightenedmetabolicdemandforenergy,protein,glucose,thiaminandpyridoxine.• Metabolicrequirementsare20%to30%higher.• Maybenefitfromearlyinitiationofenteralnutritionsupporttohelpdecreaseproteincatabolism.• Initialfeeds:20-25kcal/kgbodyweight/day.• Recoveryphase:30kcal/kgbodyweight/day.
TakeHomePoints
• Nutrition-relateddisorders,especiallyprotein-caloriemalnutritionandmicronutrientdeficiencies,arecommoninpatientswithadvancedliverdisease.Therefore,aggressivenutritionmanagementispertinenttotheiroverallmedicalcare.• Proteinandenergyrequirementsareelevated,butmostadvancedliverdiseasepatientsareunderfedduetofearsofproteinintoxication.
References
1. Krenitsky,J.NutritionforPatientswithHepaticFailure.PracticalGastroenterology.NutritionIssuesinGastroenterology,Series#6.June2003.
2. Krenitsky,J.NutritionUpdateinHepaticFailure.PracticalGastroenterology.NutritionIssuesinGastroenterology,Series#128.April2014.
3. McDowellTorresD,MullinGE.LiverDisease.TheHealthProfessional’sGuidetoGastrointestinalNutrition.2015;129-135.
4. BémeurC,DesjardinsP,ButterworthRF.RoleofNutritionintheManagementofHepaticEncephalopathyinEnd-StageLiverFailure.JournalofNutritionandMetabolism.2010;12pages.
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