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Wednesday, September 24, 2008

Diet & Nutrition in Liver Disease :: Preparing for Transplant

Purpose: Dietary modification for the patient presenting for liver
transplantation are designed to ameliorate the symptoms of End
Stage Liver Disease (ESLD) and to optimize preoperative

nutritional status.

Post operatively, the diet is designed to provide appropriate
nutrients to promote anabolism and wound healing, to
prevent and treat postoperative complications, and
to manage the nutritional side effects of immunosuppressive
and other drugs.

Use: This diet is used in the treatment of
ESLD patients undergoing liver transplant.

This diet is used in the treatment of ESLD patients
undergoing liver transplant.


Nutritional modification for the liver transplant recipient can
be classified into the following stages.

Pre Operative Stage:

As a primary metabolic organ, the liver, orchestrates a
complex array of physiologic and biochemical processes,
one of which is the regulation of protein and energy
metabolism. Consequently, it is not surprising that
Protein calorie malnutrition (PCM) is a common
complication of advanced liver disease. Malnutrition
in patients with ESLD is multifactorial. However,
major determinants are abnormal nutrient and
calorie intake, decreased intestinal absorption and
metabolic disturbances. It is worth noting that
the pattern of malnutrition seems to differ between
sexes, with muscle wasting being more in men, and
fat depletion more frequent in women.

Goals of Nutritional therapy in ESLD patients
waiting for Liver transplant.

- Correct malnutrition and prevent metabolic

- Correct malnutrition and prevent metabolic complication

- Educate patients and caregivers on individual plan for
nutrition and level of activity.

- Improve quality of life.

- Reduce perioperative complications after transplantation.

Nutrition recommendations for ESLD patients
before liver transplant

Energy needs are estimated at 1.2 to 1.4 times greater
than the Harris-Benedict calculation of Basal Energy
Expenditure (BEE). In patients with significant
ascites / edema, this calculation should be based
on an adjusted body weight, usually a reference desirable
weight or an estimate of dry weight.

Oral intake should be monitored frequently with
calorie counts, and if suboptimal, enteral feeding
(NJ) with a small bore feeding tube should be considered.

Protein needs are estimated minimally at 1g to 1.2g per
kilogram and may range up to 1.5g per kg. In general,
dietary proteins are limited only in patients with severe
hepatic encephalopathy to 0.6 – 1.0g / kg and consider
use of Branched Chain Amino Acid (BCAA) enriched formula.

Salt is usually restricted 1 to 2g per day or less for
patients with ascites. However, salt restriction
significantly decreases the palatability of the diet and
consequently may diminish food intake.

Patients with persistent, significant hyponatremia after
salt restriction and diuretic adjustment may also need fluid
restriction, usually limited to 1 liter to 1.5 liter per day.

A multivitamin with minerals according to the RDA levels
may be useful to prevent potential deficiencies associated
with poor intake, the metabolic disturbances of liver disease
and drug effects.

Frequent small feedings are used to address the early
satiety and anorexia experienced by patients with ascites.

Immediate Post operative state

As in the pre transplant period, nutrition
care must be individualized. Nutritional status
during this stage is affected by

As in the pre transplant period, nutrition care must be
individualized. Nutritional status during this stage is affected by
- Graft function
- Pre-existing malnutrition
- The stress response to surgery
- Catabolic effects of high-dose steroids.
- Post operative complications (bleeding, renal failure,
sepsis, or rejection that may occur)
Adjustments in calories, protein and electrolytes are made
based on frequent reassessments of the available clinical
and laboratory data. The nutritional recommendations are
given in the following table.





120 – 130% of BEE

Maintenance: 120 – 130% BEE


1.3 – 2g / kg / day

Based on activity level


50 – 70% of calories

50 – 70% of calories


30% of calories



1200mg / day

1500mg / day

Vitamins & Minerals

According to RDA levels

According to RDA levels

Estimated energy requirements in the immediate post
operative stage are similar to those preoperatively, and
the same guidelines may be used. Avoid over feeding.

Protein catabolism is increased after liver transplantation
and positive nitrogen balance may be difficult to achieve
in the first week or longer post operatively. Administration
of 1.3 to 2g / kg / day is suggested as an initial estimate
in patients without significant azotemia.

Fluid administration must be individualized.

Ideally, patients would move quickly to an oral
diet after transplant. Unfortunately, resumption
of substantial intake is often delayed for medical
reasons and those who experience prolonged
post operative complications – so either
TPN or Nasoenteric tube feeding is recommended
as soon as the patient is hemodynamically stable.
This is usually possible within the first 18 to 24 hours post

An oral diet is resumed when the patient’s mental and
physical status allows. A liquid to solid diet progression
is implemented according to patient tolerance.

Small, frequent feedings, including high calorie, high-protein
supplements, are often necessary until the patient is
reliably able to consume adequate nutrients orally.
Daily calorie counts are useful in assessing readiness
to wean from supplemental nutrition support.

Long term Management

With recovery, nutritional modifications are aimed
at prevention of chronic health problems common in transplant
patients. These include

- Diabetes

- Hypertension

- Hyperlipidemia

- Excessive weight gain

· Calories should be adjusted to maintain desirable body weight

· Protein needs stabilize as maintenance steroid doses are reached
and are estimated at 1g/kg/day.

NOTE: For any further clarification with regard to your
diet, contact your dietitian.

For any further clarification with regard to your diet, contact
your dietitian.


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