nutrition & liver disease

7/30/2019 Nutrition & Liver Disease

1/27

Nutrition & Liver Disease

Dr Nugroho Abikusno

Medical NutritionTrisakti University Jakarta


2/27

The major forms of liver disease are:

Acute viral hepatitis

Fulminant hepatitis

Chronic hepatitis Alcoholic hepatitis

Cirrhosis

Cholestatic liver diseases Primary biliary cirrhosis

Sclerosing cholangitis


3/27

Inherited Disorders

Hemochromatosis

Inherited disease of iron overload

Wilsons diseaseAutosomal recessive disorder

associated with impaired biliary copper

excretion 1-antitrypsin deficiency

Causes cholestasis or cirrhosis and can cause

liver and lung cancer


4/27

Other Liver Diseases

Several other causes of liver disease, including

Liver tumors

Systemic diseases (rheumatoidarthritis, systemic sclerosis)

Nonalcoholic steatohepatitis

Acute ischemic and chroniccongestive hepatopathy

Parasitic, bacterial, fungal, and

granulomatous liver diseases


5/27

Common Laboratory Tests Used to Test

for Liver Function

Hepatic excretion

- Total serum bilirubin, urine bilirubin

Cholestasis tests- Serum alkaline phosphatase

Hepatic enzymes

- ALT, AST


6/27

cont

Serum proteins

- PT, PTT, serum albumin

Markers of specific liver diseases- Serum ferritin, ceruloplasmin

Specific tests for viral hepatitis

- IgM anti-HAV, anti-HBS, HCV-RNA


7/27

End-Stage Alcoholic Liver Disease

Possible Characteristics

Malnutrition

Portal hypertension with varices

Ascites Hyponatremia

Hepatic encephalopathy

Glucose alterations


8/27

cont

Fat malabsorption

Osteopenia

Thrombocytopenia with anemia


9/27

Clinical Manifestations of Cirrhosis

Icteric sclerae

Palmar erythema

Ascites Testicular atrophy

Edema

Muscle wasting Jaundice

Bruising


10/27

Clinical Manifestations of Cirrhosis

Encephalopathy

Esophageal varices

Portal hypertension Cirrhosis

Hepatorenal syndrome

Tea-colored urine Clay-colored stool


11/27

Malnutrition in Liver DiseaseCause

Anorexia (inadequate oral intake)

Early satiety or dysgeusia

Nausea and vomiting Maldigestion and malabsorption

Altered metabolism

Restricted diets


12/27

Amino Acids Commonly Altered

in Liver Disease Aromatic amino acidsserum levels increased

Tyrosine

Phenylalanine*

Free tryptophan*

Branched-chain amino acidsserum levels decreasedValine*

Leucine*

Isoleucine*

Other amino acidsserum levels increased

Methionine*Glutamine

Asparagine

Histidine*


13/27

Nutrition Assessment Tests Affected in

Patients with End-Stage Renal Disease

Body weight

Anthropometric

measurements

Creatinine-height index

Nitrogen balance

studies

3-methylhistidine

excretion

Visceral protein levels

Immune function tests


14/27

Medical management

Diuretic therapy

Medication for encephalopathy (eg. Lactulose

& neomycin)

Management of portal hypertensive bleeding

(eg. Pharmacologic therapy, shunts, banding)

Monitoring of blood glucose


15/27

Medical nutrition therapy for cirrhosis

Recommend smaller meals because of early

satiety and anorexia; smaller meals also may

help to promote a positive nitrogen balance

and prevention of hypoglycemia

Recommend oral nutritional supplements

Consider nutritional support, if patient is

unable to consume 0.8 g protein g/kg/day and

30 kcal/kg/day


16/27

cont

Patient may necessitate 120%-140% of REE inend-stage liver disease without ascites; and up to150%-175% of REE if ascites, malabsorption, orinfection is present

Make sure to obtain dry weights for reassessmentpurposes

Liver failure reduces glucose production anddecreases peripheral utilization; coupled with a

change in hormones, such as insulin, glucagon,cortisol, and epinephrine, the body developspreference for lipids and amino acids


17/27

cont

Twenty-five percent to 40% of total caloriesshould come from lipid

Patient should receive 1.2-1.3 g protein/kg/day to

promote positive nitrogen balance; 1.5 gprotein/kg/day if patient shows signs of severeascites or gastrointestinal bleeding

Vitamin and mineral supplementation

recommended for end-stage liver diseaseincludes all of the B vitamins and all of the fat-soluble vitamins


18/27

cont

Wernickes encephalopathyrecommend

thiamine, vitamin B6, vitamin B12, folate, and

niacin

Iron supplementation recommended in cases ofgastrointestinal bleeding

Zinc, magnesium, and copper are malabsorbed in

chronic liver disease with steatorrhea Between 10% and 37% of patients with cirrhosis

will develop overt diabetes mellitus


19/27

Medical nutrition therapy for portal

hypertension

Acute stageinitiation of TPN probably

necessary

Repeated endoscopic therapy is likely to cause

esophageal stricture or dysphagia

Shunt placement increases the risk of

encephalopathy and reduces nutrient

metabolism


20/27

Medical nutrition therapy for ascites

Recommend fluid restriction

Watch for loop diuretic side effects, includinghyponatremia, hypokalemia,

hypomagnesemia, hypocalcemia, andhypochloremic acidosis

Monitor weight, abdominal girth, urinary

sodium concentration, BUN, creatinine,albumin, uric acid, and electrolyte levels, ifpatient is prescribed diuretics


21/27

cont

Recommend 2 g/day for sodium restriction

Ensure that patient receives adequate protein

M di l t iti th f h ti


22/27

Medical nutrition therapy for hepatic

encephalopathy (including fulminant

hepatitis) Ammonia is an important causative factor,because the liver can not detoxify ammonia to

urea

Some people believe that dietary protein

causes an increase in ammonia production,

but this is unproven; protein restriction is not

recommended, with some studies showingthat this practice is possibly quite harmful


23/27

cont

A branched-chain amino acid formula isrecommended for patients who cannot toleratestandard protein sources and are nonresponsive

to medication Some studies have shown that vegetable protein

and casein are the preferred sources of proteinfor patients with hepatic encephalopathy,

because they contain less aromatic amino acidsand more branched-chain amino acids than othersources of protein


24/27

cont

Monitor glucose regularly

Vitamin K supplementation is recommended


25/27

Medical nutrition therapy for fat

malabsorption in liver disease

Replace long-chain triglycerides with medium-

chain triglycerides, because they are more

readily digestible

Recommend a 40-g fat diet; if diarrhea does

not resolve quickly as a result of this diet,

discontinue the diet because of the risk of

furthering malnutrition


26/27

Medical nutrition therapy for liver

transplant

Pretransplantmalnutrition is common

Recommend small, frequent, nutritionally

complete meals, with enteral feedings as

necessary

Food-drug interactions are common

Posttransplantprovide nutritional

intervention as necessary for obesity,

hyperlipidemia, hypertension, diabetes, etc


27/27

References and recommended

resources

Hasse JM, Matarese LE. Medical nutrition

therapy for liver, biliary system, and exocrine

pancreas disorders. In: Mahan LK, Escott-

Stump S. Krauses Food, Nutrition, and Diet

Therapy. 11th ed. Philadelphia, PA: WB

Saunders; 2004:740-756.

nutrition & liver disease

Documents