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Wednesday, November 5, 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.

Modification:

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 complication

- 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.

NUTRITION RECOMMENDATIONS AFTER TRANSPLANT


SHORT TERM

LONG TERM

Calories

120 – 130% of BEE

Maintenance: 120 – 130% BEE

Protein

1.3 – 2g / kg / day

Based on activity level

Carbohydrate

50 – 70% of calories

50 – 70% of calories

Fat

30% of calories

<30%>

Calcium

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 operatively.

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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