Anaemia

What happens when you suffer from anaemia?

Anaemia is a condition in which the quantity of heamoglobin in the body goes down. Heamoglobin, as we know, is a protein that is very essential to the body. It supplies oxygen to different parts of the body and it does many other functions. If it is low, each and every part of the body gets affected. The first implication would come because there is not sufficient oxygen being transported to different areas. All parts of the body would start feeling weak.

What diet should be prescribed for an anaemic person?

I must clarify that anaemia by itself is not a disease. Anaemia is a manifestation of a particular disease. The real treatment would be to treat the cause. Say, if diet is responsible for anaemia, then taking a good diet could make a difference. There is usually a deficiency of iron or another vitamin. It could be vitamin B12, it could be folic acid or it could be pyridoxine. Deficiency of these things in the diet can lead to anaemia. In case there is iron deficiency, then one has to ensure that whatever food item one takes should contain enough of iron and it should be made available to the body; that means it should get absorbed also.

Should one take supplements or natural forms of iron?

There is no doubt that the natural forms are the best ways of supplementing. But having said it, there are certain problems. Vitamin B12 is not found in vegetarian diet. It is largely a vitamin found in non-vegetarian diet. I would not want any vegetarian to change to a non-vegetarian for the sake of vitamin B12. It is much cheaper, it is more effective and it is more social to supplement with the tablets of B12.

So, basically, if you are not getting it from your daily intake of food, then you have to supplement it with pills. What are the tests to diagnose anaemia?

Anaemia is the reduction of the haemoglobin level in the body. Normally this varies with the age and gender of the individual. According to the WHO criteria, an adult male having the haemoglobin of less than 13, an adult non-pregnant female having a haemoglobin of less than 12 and a pregnant lady having a haemoglobin of less than 11 is diagnosed as anaemic. A simple test is a complete blood count, which gives us a value of haemoglobin and certain other rates and indexes that help us to diagnose a patient as anaemic.

What are the levels of haemoglobin in children?

The values in children tend to vary from the time of birth till about the age of 12 years, though the gender differences do not come till puberty. The value for a newborn is round 13. They vary from the age of six months to one year, two years to six years and again 12 years. So, these are the criteria, which decide whether the child is anaemic or not.

How does a newborn supplement iron? Does it come entirely from the mother’s milk?

When a child is born his haemoglobin is more than the adult’s hemoglobin. Milk that he consumes is deficient in iron, just remember milk is deficient in iron, and that goes on for the whole first year of his life. That is the time by end of first year his haemoglobin drops down to as low as 11, that is normal for them. What we have to remember is that during this time he should be given iron supplementation.

Are only women affected by anaemia?

Not at all, this is a wrong notion that women are the only ones to get affected. However, women have a regular monthly blood loss. In addition to that, married women also might have blood loss during pregnancy or might even have to give away some of their iron and essential elements to the child. This is the reason why women tend to have more prevalence of anaemia as compared to men.

Is there a reserve of iron in the body?

If body needs about 100 mg of iron on a day-to-day basis, 99% of it is recycled and one milligram is taken from the diet. Now, that one milligram is sufficient to manage the requirement of 100 mg because the rest is recycled. Since it is such an essential element in the human body, nature has created a separate reserve for it. So even if somebody does not take iron for a month it should not affect him because he can fall back upon that reserve. By the time anaemia develops, these reserves would have been used up altogether.

Is it true that vegetarians are more likely to be anaemic than non-vegetarians?

The risk of a vegetarian getting into an anaemic state occurs only because of B12 deficiency. We have a large population in our country that is vegetarian. In our clinical practice, we see that most of them do not become deficient in this essential vitamin. So, a healthy person is not likely to get anaemic but there are chances that a vegetarian might get deficient in B12, which may or may not lead to anaemia.

How is thalassaemia related to anaemia?

Thalassaemia is a hereditary disorder, which presents itself as anaemia. It is a very frequent problem in India because we have a large gene pool of beta thalassaemics in India. And it presents itself, in a fashion, in a laboratory very similar to iron deficient anaemia, but there are simple tests which are available which help us distinguish between a thalassaemic and an iron deficient individual. A simple estimation of haemoglobin A2 levels and a fetal hemoglobin level estimation with the examination of the complete blood count should by and large be able to give the diagnosis.

What is bone marrow biopsy and does it help in determining anaemia?

A bone marrow biopsy is an investigative technique in which a small needle is inserted into the bone and a piece of the marrow tissue is taken out. As far as the diagnosis of anaemia is concerned, this is rarely restored to, even though staining of the bone marrow iron is supposed to be the most definitive test for iron deficiency. If a patient’s bone marrow does not stain positive for iron it means the patient is completely depleted of iron. But being an invasive technique and with the presence of so many more simple techniques available to us, we do not resort to it. However, it is an important investigation as part of the diagnosis of a patient who is having unexplained anaemia in which he would like to rule out the secondary causes of anaemia, like cancers, like leukaemia or myelodysplastic syndromes in an elderly individual.

Are chemotherapy patients more likely to be anaemic?

Certain groups of anticancer drugs, which act against the folate metabolism can cause anaemia.

By and large all anticancer drugs would have some affect on the bone marrow. Bone marrow is a factory for the production of haemoglobin. Whenever there is anaemia, it is important to check the factory, whether it is working or not. All anticancer drugs can have an affect on this bone marrow.

Is there any way to prevent anaemia?

Yes, and I think that is the best strategy. We have preventive strategies for both kind of anaemias - the hereditary type of anaemia and those that are acquired. I will take the acquired one first because they are more common. Acquired, they are from the deficiency of iron or one of the vitamins such as — B12 or deficiency of protein. It is very easy for anybody to take a healthy diet, a nutritious diet and a balanced diet. Highly processed foods destroy folic acid resulting in anaemia. One should avoid taking tea; one can take some lemon or vitamin C that helps absorb iron. When it comes to the hereditary causes, like thalassaemia: one can prevent it; in fact, some of the countries are going to eradicate thalassaemia by genetic conunselling, which is a preventive and curative measure.

"A large number of diseases are potentially treatable by liver transplants."

1) What diseases are treated by liver transplantation?

A large number of diseases are capable of interfering with the liver's function sufficiently to threaten the life of the patient and most are potentially treatable by liver transplantation.

2) Which liver diseases are the most common?

In adults, cirrhosis, the death of liver cells due to a variety of causes, is one of the most common reasons for which liver transplantation is done. In children, the disease most often treated by liver transplantation is biliary atresia, a failure of the bile ducts to develop normally to drain bile from the liver.

3) What about alcohol-related liver disease?

Many people who develop cirrhosis of the liver due to excessive use of alcohol do need a liver transplant. Abstinence from alcohol and treatment of complications for 6 months will usually allow some of them to improve significantly and these patients may survive for prolonged periods without a transplant. For patients with advanced liver disease, where prolonged abstinence and medical treatment fails to restore health, liver transplantation is the treatment.

4) And cancer of the liver?

Primary liver cancers develop at a significantly higher rate in cirrhotic livers as compared to normal livers. Particularly in patients having liver disease secondary to Hepatitis B. Liver Transplantation at an early stage of liver cancer may result in long-term survival for select patients.

However, cancers of the liver that begin somewhere else in the body and spread to the liver are not curable with a liver transplant.

5) Are there alternative treatments for liver disease?

There are effective medicines for some liver diseases, while for others only palliative treatment for complications is available. Treatment of complications may be all that is required if the liver is not failing. Frequently medical treatment delays, but does not eliminate, the need for transplantation.

6) Is liver transplantation a treatment of last resort, when everything else has failed?

Yes and no. If medical treatment is likely to allow prolonged survival with good quality of life, transplantation would be reserved for the future. However, ideally the surgery is undertaken before the terminal stage of the disease when the person is too ill to withstand major surgery. For patients with poor quality of life due to complications of liver cirrhosis liver transplantation should be undertaken at an optimal state of health in-order to avail good outcomes.

7) How is the decision made to transplant?

This is a decision made in consultation with all individuals involved in the patient's care, doctors as well as the patient’s family. The patient and family's input is vital and they must clearly understand the risks & benefits involved with proceeding to transplantation.

8) What are the major risks?

Before surgery, the risks are mainly the development of some acute complication of the liver disease, which might render the patient unacceptable for surgery. With transplantation there are risks common to all forms of major surgery, as well as technical difficulties in removing the diseased liver and implanting the donor liver. One of the major risks for the patient is not having any liver function for a brief period. Immediately after surgery, bleeding, poor function of the grafted liver, and infections are major risks. The patient is carefully monitored for several weeks for signs of rejection of the liver.

9) What are the overall chances of surviving a liver transplant?

This depends on many factors but overall 85 - 90 percent of children & adults survive and are discharged from the hospital.

10) How long does it take to recover?

In part this depends on how ill the individual was prior to the surgery. Most patients should count on spending a few days in an intensive care unit and about four weeks in the hospital, as a minimum.

11) What happens during this recovery period?

Initially in the intensive care unit there is very careful monitoring of all body functions including the liver. Once the patient is transferred to the ward, the frequency of blood testing, etc. is decreased, eating is allowed and physiotherapy is used to regain muscle strength. The drug or drugs to prevent rejection are initially given by vein, but later by mouth. During the transplantation, frequent tests are done to monitor liver function and detect any evidence of rejection.

12) If a transplanted liver fails to function, or is rejected, what can be done?

There are varying degrees of failure of the liver, however, and even with imperfect function, the patient will remain quite well. Occasionally, when circumstances and time permit, a failing transplanted liver can be replaced by a second (or even third) transplant. Unfortunately, there is no dialysis treatment for livers as is possible with kidneys. Researchers are experimenting with devices to keep patients with failing livers alive while waiting for a new liver.

13) What side-effects do patients commonly experience from the drugs used to treat or prevent rejection?

All the drugs used for rejection increase the person's susceptibility to infections (and possibly to the development of tumors). Various medicines are used, and each has its own effects. Cortisone-like drugs produce some fluid retention and puffiness of the face, risk of worsening diabetes and osteoporosis (a loss of mineral from bone). Cyclosporine produces some tendency to develop high blood pressure and the growth of body hair. The dose of this medication must be very carefully regulated. Kidney damage can occur from cyclosporine but this can usually be avoided by monitoring the drug levels in the blood. Common side effects for FK-506 include headaches, tremor, diarrhea, increased tension, nausea, increased levels of potassium and glucose and kidney dysfunction.

14) Do recipients of liver transplant have to take these medicines for the rest of their lives?

Usually. However, as the body adjusts to the transplanted liver, the amount of medicine needed to control rejection is reduced. There are patients who have been successfully taken off these drugs. Researchers are attempting to determine why this has been successful in these cases.

15) How frequent is medical follow-up?

Routine follow-up consists of monthly blood tests, measuring of blood pressure by a local physician with annual or semi-annual checkups at the transplant center.

16) Are patients more susceptible to other infections?

Recipients should avoid exposure to infections as the immune system is depressed. Illness should be reported to the doctor immediately and medicines taken only under medical supervision.

17) What about physical activity after a liver transplant?

Most patients are able to return to a normal or near-normal existence and can participate in fairly vigorous physical exercise six to twelve months after a successful liver transplant.

18) What about sexual activity?

As with other physical activities, sexual activity may be resumed.

19) Is it safe for women to become pregnant after transplantation?

Studies have shown that women who undergo liver transplantation can conceive and give birth normally, although they have to be monitored carefully because of a higher incidence of premature births.
Mothers are advised against nursing babies because of the possibility of immunosuppressive drugs being ingested by the infants through breast milk.

20) What about diet?

Transplant patients have a tendency to gain weight because of their retention of water. They are advised to lower their intake of salt to reduce or eliminate this water retention. Otherwise patients should maintain a balanced diet.

21) Can there be a recurrence of the original disease in the transplanted liver?

If the disease was caused by hepatitis B or hepatitis C viruses then recurrence is likely. Other types of liver disease do not recur.

22) From the description, patients with successful liver transplants seem very healthy. How long can this good health last?

The newness of this procedure makes this question difficult to answer. There is every indication that those who are well after one year remain so indefinitely.

23) Where do the donor livers come from?

Livers are donated, with the consent of the next of kin, from individuals who have brain death, usually as a result of a head injury or brain hemorrhage. When such a donor is identified, transplant centers are contacted by a computer network and arrangements are made to retrieve whatever organs may be donated. Frequently this involves a team from a transplant center flying to the donor hospital to remove the organs, and returning with them for the transplant operation.

24) Do the donor and the recipient have to be matched by tissue type, sex, age, etc.?

No. For liver transplants, the only requirements are that the donor and recipient need to be approximately the same size, and of compatible blood types. No other matching is necessary.

25) What happens if there are two suitable recipients for a donated liver?

This is unusual in practice but the decision would be to transplant the patient with the more urgent need.
No. For liver transplants, the only requirements are that the donor and recipient need to be approximately the same size, and of compatible blood types. No other matching is necessary. This is unusual in practice but the decision would be to transplant the patient with the more urgent need.

26) How can I donate my organs?

If you wish to be an organ donor, carry an organ donor card and place an organ donor sticker on your medical identification card. It is important to discuss organ donation with family members since they will have to give consent. An organ donor card is available from the MOHAN Foundation and at SGRH (Sir Ganaga Ram Hospital) Delhi.

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.

Diet in Liver Disease

What is the energy requirement of patient suffering from liver disease?
A high energy intake is required to promote weight gain and to ensure maximum protein utilisation. Initially, a patient is put on 1500 - 2000 cal. because of anorexia. Gradually the energy intake may be increased to 20 - 30% more than the normal intake.

How much carbohydrates should be consumed?
A high carbohydrate diet is recommended to provide bulk of the energy to build.up glycogen stores in the liver as well as for their protein sparing action. A daily.intake of 300 - 400 gms of carbohydrates like glucose, sugar, honey, fruits and .fruit juices and also from starches like cereals and root vegetables is recommended.

How much fat should be consumed?
Patients of liver disease can freely consume 20 – 30 gms of fats per day without.any apprehension unless there is nausea. Preferred sources are Medium Chain Triglycerides (MCT’s) – coconut .oil, butter, cream & emulsified fats such as from milk & eggs.

How much protein should be consumed by a liver disease patient?
Protein intake depends on the stage of liver disease. Generally the patients is put on 1- 1.5 gms per Kg body weight for regeneration of liver cells with emphasis on vegetable proteins (milk and milk products, pulses, legumes, and nuts) as they have branched chain amino acids i.e. isovaline, leucine and isoleucine. Animal proteins (meat, fish and poultry) have aromatic amino acids-tryptophan, tyrosine, phenylalanine, methonine which can lead to hepatic encephalopathy.

When is a liver disease patient put on sodium and fluid restriction?
A patient who has developed “ascitis” with accumulation of fluids comprisingof protein, sodium & water in the abdominal cavity, is put on sodium and fluid restricted diet.

Why are Vitamin B, Vitamin C and Vitamin K important?
The requirement of B group of vitamins are increased due to increased energy. metabolism, higher amount of Vit C (amla, lemon, guava, citrus fruits etc.) are needed for tissue healing. Vitamin K foods (green leafy vegetables) are required to correct increased prothrombin time.

What minerals should be included in liver disease patient?
All minerals, particularly
a) Calcium (milk and milk products) because these patients have a.tendency to develop osteopaenia.
b) Iron (jaggery, beet root, raisins, lotus stem) in case of oesophageal varices (enlarged veins) with danger of rupture & haemorrhage.

When is fibre restricted in liver disease diets?
The fibre is restricted in cirrhotic patients with oesophageal varices.

What role does turmeric play in liver disease?
Turmeric has an antioxidant “curcumin” which stimulates the production of good enzymes in liver. These enzymes help in removing toxins, carcinogens & other metabolites from the body via faeces and urine.

How are cruciferous vegetables beneficial in liver disease?
Cruciferous vegetables (Broccoli, Cabbage, Cauliflower) contain phytochemical i.e. indoles, isothiocinates which help in production of enzymes glutathione S. transferase that help in detoxification of metabolites and carcinogens in the liver.

What are the ways to improve palatability in liver disease diet?
Alternate seasoning like tamarind and lemon, vinegar, mango powder may be used to enhance the flavour of the food.

What are the tips to deal with anorexia and loss of appetite?

Nausea
- If some smell makes you feel sick, take a breath of fresh air before you eat.
- Keep your mouth fresh by brushing your teeth, using a mouth wash or sucking mints.
- Don’t let yourself get too hungry. Hunger makes nausea worse.
- Take small frequent meals.
- Cold snacks are easier to cope with as they don’t smell much.
- A nutritious small snack may replace a proper meal.
- Eat when you are relaxed.
- High calorie and protein supplements can be used if you are loosing weight.

Loss of appetite
- Eat small frequent meals take a nutritious snack instead of big meal.
- Choose foods that you like.
- Try to relax before and after you eat.
- Eat slowly chew well and breath steadily.
- A nourishing drink like milkshake, milo, complan may be had if you don’t like solid foods.

Can alcohol be consumed?
Alcohol should not be consumed as it has a damaging effect on liver.

LIVER TRANSPLANT SURGERY

LIVER TRANSPLANT SURGERY

During the operation, surgeons will remove your liver and will replace it with the donor liver. Because a transplant operation is a major procedure, surgeons will need to place several tubes in your body. These tubes are necessary to help your body carry out certain functions during the operation and for a few days afterward:

• Liver transplant surgery is extremely complex and may last 4 to 12 hours.
• The patient will be under general anesthesia throughout the surgery.
• The incision on the belly is in the shape of an upside-down Y.
  
  
  
• A nasogastric tube will be inserted through your nose into your stomach.
• The nasogastric tube will drain secretions from your stomach, and it will remain in place for a few days until your bowel function returns to normal.
• During the liver transplant operation, a tube will be placed through your mouth into your windpipe (trachea) to help you breathe during the operation and for the first day or two following the operation.
  
  
  
• The tube is attached to a ventilator that will expand your lungs mechanically.
• Small, plastic, bulb-shaped drains are placed near the incision to drain blood and fluid from around the liver. These are called Jackson-Pratt (JP) drains and may remain in place for several days until the drainage significantly decreases.
• A tube called a T-tube may be placed in the patient's bile duct to allow it to drain outside the body into a small pouch called a bile bag.
  
  
  
• The bile may vary from deep gold to dark green, and the amount produced is measured frequently. The tube remains in place for about 3 months after surgery.
• Bile production early after the surgery is a good sign and is one of the indicators surgeons look for to determine if the liver transplant is being "accepted" by the patient's body.

POST OPERATIVE CARE

After surgery, the patient is taken to the intensive care unit, is monitored very closely with several machines. The patient will be on a respirator, a machine that breathes for the patient, and will have a tube in the trachea (the body's natural breathing tube) bringing oxygen to the lungs. Once the patient wakes up enough and can breathe alone, the tube and respirator are removed. The patient will have several blood tests, x-ray films, and ECGs during the hospital stay. Blood transfusions may be necessary. The patient leaves the intensive care unit once he or she is fully awake, able to breathe effectively, and has a normal temperature, blood pressure, and pulse, usually after about 3-4 days. The patient is then moved to a room with fewer monitoring devices for a few days longer before going home. The average hospital stay after surgery is 1-3 weeks.

A cardiac monitor or ECG machine is used so the doctor can see the heart rate and rhythm. There is a screen to show the wave form and number display. A cable from this machine which has 3 smaller cables is attached to0 your chest. There are also some beeps and buzzers that will go off from time to time.

Your blood pressure is also monitored and shown on the screen. As already mentioned you will not be able to eat or drink at first. To keep you more comfortable there will be another tube though your nose which empties your stomach. This tube is called a nasogastric tube. It is important because it can prevent nausea and vomiting. The nasogastric tube will be removed later in your recovery period. Your abdomen will be very sore post operatively because of the large incision made for the transplant. It is held together with the sutures or staples which are removed after healing has taken place.

In your immediate post operative period keeping track of fluid intake and output is critical. To accurately measure your urine output a foley catheter is necessary.

There will be some small tubes existing from the abdomen. Three small tubes called Jackson-Pratt drains or J.P’s are connected to suction bulbs to drain excess fluid from around the operative site where the new liver sits. As you recover and the excess fluid is removed the tubes will be removed. A small bag will also be present. It is called a bile bag and is connected to a T tube which sits in the common bile duct. Bile production is important and the collection of bile and its testing helps us determine liver function.

Diet: It is extremely important to follow the diet regimen as advised by the hospital dietician and the operating doctor during the hospital stay and after discharge of the patient. As liver transplant is a major surgery the food intake of the patient and monitoring of the same is very important as per the advice of the operating surgeon.

Medications: The immune system of the patients body doesn’t accept the donated liver as its own organ. It starts rejecting it. The operating surgeon will prescribe immuno suppressive medication and other medications for the patient recovery and acceptance of the donated liver. You must take these medications regularly as advised by the operating surgeon and till the time they are advised.

Diet & Nutrition in Liver Disease :: Nutrition guidelines

Diet & Your Liver What does nutrition have to do with your liver? Nutrition and the liver are interrelated in many ways. Some functions are well understood; others are not. Since everything we eat, breathe and absorb through our skin must be refined and detoxified by the liver, special attention to nutrition and diet can help keep the liver healthy. In a number of different kinds of liver disease, nutrition takes on considerably more importance. Why is the liver so important in nutrition? 85-90% of the blood that leaves the stomach and intestines carries important nutrients to the liver where they are converted into substances the body can use. The liver performs many unique and important metabolic tasks as it processes carbohydrates, proteins, fats and minerals to be used in maintaining normal body functions. Carbohydrates, or sugars, are stored as glycogen in the liver and are released as energy between meals or when the body's energy demands are high. In this way, the liver helps to regulate the blood sugar level, and to prevent a condition called hypoglycemia, or low blood sugar. This enables us to keep an even level of energy throughout the day. Without this balance, we would need to eat constantly to keep up our energy. Proteins reach the liver in their simpler form called amino acids. Once in the liver, they are either released to the muscles as energy, stored for later use, or converted to urea for excretion in the urine. Certain proteins are converted into ammonia, a toxic metabolic product, by bacteria in the intestine or during the breakdown of body protein. The ammonia must be broken down by the liver and made into urea which is then excreted by the kidneys. The liver also has the unique ability to convert certain amino acids into sugar for quick energy. Fats cannot be digested without bile, which is made in the liver, stored in the gallbladder, and released as needed into the small intestine. Bile (specific bile "acids"), acts somewhat like a detergent, breaking apart the fat into tiny droplets so that it can be acted upon by intestinal enzymes and absorbed. Bile is also essential for the absorption of vitamins A, D, E, and K, the fat soluble vitamins. After digestion, bile acids are reabsorbed by the intestine, returned to the liver, and recycled as bile once again. Can poor nutrition cause liver disease? There are many kinds of liver disease, and the causes of most of them are not known. Poor nutrition is not generally a cause, with the exception of alcoholic liver disease and liver disease found among starving populations. It is much more likely that nutrition is the result of chronic liver disease, and not the cause. On the other hand, good nutrition - a balanced diet with adequate calories, proteins, fats, and carbohydrates - can actually help the damaged liver to regenerate new liver cells. In fact, in some liver diseases, nutrition becomes an essential form of treatment. Patients are strongly advised not to take megavitamin therapy or to use nutritional products bought in special stores or by catalogue without consulting a doctor. How does liver disease affect nutrition? Many chronic liver diseases are associated with malnutrition. One of the most common of these is cirrhosis. Cirrhosis refers to the replacement of damaged liver cells by fibrous scar tissue which disrupts the liver's important functions. Cirrhosis occurs as a result of excessive alcohol intake (most common), common viral hepatitis, obstruction of the bile ducts, and exposure to certain drugs or toxic substances. People with cirrhosis often experience loss of appetite, nausea, vomiting and weight loss, giving them an emaciated appearance. Diet alone does not contribute to the development of this liver disease. People who are well nourished, for example, but drink large amounts of alcohol, are also susceptible to alcoholic disease. Adults with cirrhosis require a balanced diet rich in protein, providing 2,000 to 3,000 calories a day to allow the liver cells to regenerate. However, too much protein will result in an increased amount of ammonia in the blood; too little protein can reduce healing of the liver. Doctors must carefully prescribe the correct amount of protein for a person with cirrhosis. In addition, the physician can use two medications (lactulose and neomycin) to control blood ammonia levels. What other nutritional problems are caused by cirrhosis? When the scarring of cirrhosis interferes with the flow of blood from the the stomach and intestines to the liver, a condition called portal hypertension may develop. This simply means that there is back pressure in the veins entering the liver. Surgical "shunting", or rerouting of blood away from the liver and into the general circulation can relieve this pressure, but it often causes a new set of problems. Because the shunted blood has bypassed the liver, it contains high levels of amino acids, ammonia, and possibly toxins. When these compounds reach the brain, they cause a condition called hepatic encephalopathy, which means "liver caused mental impairment." Patients become confused and some temporary loss of memory occurs. Can diet help in treating other complications of cirrhosis? There are a number of complications of cirrhosis which can be helped through a modified diet. Persons with cirrhosis often experience an uncomfortable buildup of fluid in the abdomen (ascites) or a swelling of the feet, legs, or back (edema). Both conditions are a result of portal hypertension (increased pressure in the veins entering the liver). Since sodium (salt) encourages the body to retain water, patients with fluid retention can cut their sodium intake by avoiding such foods as canned soups and vegetables, cold cuts, dairy products, and condiments like mayonnaise and ketchup. In fact, most prepared foods contain liberal amounts of sodium, while fresh foods contain almost no sodium at all. A good-tasting salt substitute is lemon juice. Are there other liver diseases where specific changes in diet can help? Nutrition and a modified diet have been found to have a significant effect on a number of other liver diseases. Some types of liver disease, for example, cause a backup of bile in the liver which is called cholestasis. This means that bile cannot flow into the small intestine to aid in the digestion of fats. When this happens, fat is not absorbed but instead is excreted in large amounts in the feces, which become noticeably pale-colored and foul-smelling. This condition is known as steatorrhea. This loss of fat calories may also cause weight loss. Special fat substitutes, such as medium chain triglycerides (MCT oil) and safflower oil can help alleviate this condition because they are less dependent on bile for intestinal absorption. They can be used like other oils in cooking, baking and salad dressings. Patients with steatorrhea may also have difficulty absorbing fat soluble vitamins A, D, E, K. However, water soluble vitamins are absorbed normally. Supplementing the diet with fat soluble vitamins is possible, though it should only be carried out under the guidance of a physician. Vitamin A in excess over what is needed is very toxic to the liver. Diet for liver disease A healthy liver is like a processing plant. Carbohydrates, proteins, fats, vitamins, and minerals all go to the liver where they are broken down and stored. Later, they are remade into whatever the body needs and carried through the bloodstream to wherever they will be used. Even when the liver is damaged, these nutrients still come to the liver after they have been digested. But, once they arrive, the liver cannot process them and they build up. This build-up causes more liver damage. As a result, what a person with liver disease eats is very important. This diet needs to provide nutrients without causing further harm to the liver. This type of diet would include: A limited amount of protein. A damaged liver cannot process protein very well. This causes a build-up of ammonia in the bloodstream. Sore carbohydrate. Carbohydrate is the body's energy supply. A healthy liver makes glycogen from carbohydrate. The glycogen is then broken down when the body needs energy. A damaged liver can't do this. Without glycogen, more carbohydrate is needed from the diet to make sure the body has enough energy. A moderate amount of fat. Fat provides calories, essential fatty acids, and fat-soluble vitamins. A limited amount of fluids and sodium. Liver damage can cause high blood pressure in the major vein of the liver. This can result in ascites, a fluid build-up in the abdominal cavity. Limiting fluids and sodium can help prevent this. Extra amounts of certain vitamins and minerals. A damaged liver has problems storing many vitamins and minerals. Liver "sluggishness" is often blamed for poor appetite, listlessness, poor digestion and bad health. In fact, only in a minority of instances, is the liver to blame in these situations. Specifically, only in liver disease which may take the form of hepatitis or cirrhosis will ill-health be due to the liver. Diet For A Healthy Liver A balanced diet with plenty of fruits, vegetables, animal protein with a fat - carbohydrate - protein ratio of 30% - 50% - 20% unless specific problems such as diabetes, kidney disease etc dictate otherwise. · Plenty of fluids Avoidance of excess alcohol Pack your diet with antioxidants Anti-oxidants protect against free radical (produced in all of us due to body's metabolic processes) injury. Apart from protecting the liver and helping in its recovery if damaged, they have been shown to inhibit cancer cells, fight the ageing process and protect he sight. Antioxidants are abundant in fruits and vegetables, as well as other foods including nuts, grains and some meats, poultry and fish. Below are some of the anti-oxidants and their best food sources. Beta-carotene Found in many foods that are orange in color, including sweet potatoes, carrots, apricots, pumpkin, and mangos. Some green leafy vegetables such as spinach and kale are also rich in beta-carotene. Lycopene A potent antioxidant found in tomatoes, watermelon, guava, papaya, apricots, oranges Selenium Selenium is a mineral, not an antioxidant nutrient. However, it is a component of antioxidant enzymes. The amount of selenium in soil, which varies by region, determines the amount of selenium in the foods grown in that soil. Plant foods like rice and wheat are the major dietary sources of selenium in most countries Vitamin A Foods rich in vitamin A include liver, sweet potatoes, carrots, milk, egg yolks and mozzarella cheese. Vitamin C This can be found in abundance in citrus fruits (lemons, oranges etc.), cereals, poultry and fish. Vitamin E This is found in almonds, in many oils including safflower, corn and soybean oils, and also found in mangos, nuts, broccoli and other foods. A host of over-the-counter anti-oxidant preparations such as Salymarin (milk thistle) can be taken although unnecessary if above foods are taken in good quantities. What is a liver disease diet? The liver is an organ in the body that does several important tasks. One task of the liver is to help the body use the nutrients in food for energy. Liver diseases such as hepatitis and cirrhosis may change the way your body uses nutrients from food. Nutrients include carbohydrate (kahr-boh-HEYE-drayt), protein, fat, vitamins and minerals. Some people with liver disease may not get enough nutrients and lose weight because of these changes. A liver disease diet provides the right amount of calories, nutrients, and liquids for you. A liver disease diet may help your liver work better and prevent other health problems. The dietary changes you will need to make depend on the type of liver disease and health problems you have. Your dietitian (di-uh-TISH-in) or nutritionist (noo-TRI-shun-ist) will tell you about the type of diet that is best for you. What can I do to make a liver disease diet part of my lifestyle? Changing what you eat and drink may be hard at first. You may need to make these changes part of your daily routine. Following a liver disease diet may help you feel better. Choose a variety of items on this diet to avoid getting tired of having the same items every day. Keep a list of items allowed on this diet in your kitchen to remind you about the diet. Carry a list of items allowed on this diet to remind you about the diet when you are away from home. Tell your family or friends about this diet so that they can remind you about the diet. Ask your caregiver, a dietitian, or a nutritionist any questions you may have about your diet plan. A dietitian or nutritionist works with you to find the right diet plan for you. These caregivers can also help to make your new diet a regular part of your life. What should I avoid eating and drinking while on a liver disease diet? The foods that you need to avoid or limit depend on the type of liver disease and health problems you have. Following are some of the dietary changes that you may need to make: Sodium: You may need to decrease the amount of sodium in your diet. Sodium causes your body to retain (hold on to) fluids. When your body holds on to fluids, you will have swelling. Your caregiver may suggest that you limit or avoid high-sodium foods. Your caregiver will give you more information about a low-sodium diet. Some foods that contain high amounts of sodium are the following: Bacon, sausage and deli meats. Canned vegetables and vegetable juice. Frozen dinners. Packaged snack foods like potato chips and pretzels. Soy, barbecue, and teriyaki sauces. Soups. Table salt. Liquids: You may also have to drink fewer liquids if you have swelling. Liquids include water, milk, juice, soda, and other beverages. It also includes any food that contains liquid, such as soup. This also includes food that melts when it is not cold, such as gelatin. Talk to your caregiver about the amount of liquid you may drink each day. Alcohol: Alcohol may make your liver disease worse. Avoid alcoholic drinks such as beer, wine, hard liquor (whiskey, gin, vodka) or mixed drinks (drinks made with hard liquor). Talk to your caregiver if you have questions about alcohol in your diet. What can I eat while on a liver disease diet? Eat ____ grams of protein each day. Eat ____ grams of sodium each day. Drink ____ ounces of liquid each day. Calories: Eat a variety of foods each day to help your liver work as well as possible, and to keep a healthy weight. You may not feel hungry or you may feel full right away after eating. This may make it hard for you to eat enough calories. Eat several small meals throughout the day instead of large meals to make sure you eat enough calories. Ask your dietitian or nutritionist how many calories you need each day. Protein: It is important to eat the right amount of protein when you have liver disease. Your dietitian or nutritionist will tell you how much protein you should have each day. The following foods are good sources of protein. The amount of protein (in grams) follows each listed food. Three ounces of meat, poultry (chicken), or fish (21 grams). One cup of milk or yogurt (eight grams). One large egg (seven grams). Two tablespoons of peanut butter (seven grams). One-half of a cup of tofu (seven grams). One-fourth of a cup of cottage cheese (seven grams). One ounce of cheese (seven grams). One-half of a cup of cooked, dried, pinto, kidney or navy beans (three grams). Fat: Your caregiver will tell you how much fat you should have in your diet each day. Some people with liver disease have problems with digesting (breaking down) and absorbing (using) fat. The fat that is not broken down and used by the body is lost in bowel movements. If you have this health problem, you may need to eat less fat. Your doctor may also suggest that you eat a special type of fat that is absorbed more easily by your body. Carbohydrates: Your caregiver will tell you how much carbohydrate you should eat each day. Carbohydrates are found in breads, cereals, grains (rice, oats), starchy vegetables (potatoes, corn, peas), and crackers. Liver disease may cause blood sugar levels to be too high or too low in some people. You may need to make changes in your diet if you have this problem. Eating certain amounts of carbohydrates at each meal helps to control blood sugar levels. What other diet guidelines should I follow? Talk to your caregiver before taking any vitamins or herbal supplements (pills). Talk to your dietitian or nutritionist about any other diet changes you should make. Liver disease may cause several different health problems. Your caregiver may suggest that you make other diet changes that can help to improve your health. Risks: You may not get enough nutrients and lose weight if you do not eat a balanced diet. Not following a liver disease diet may cause certain health problems to become worse. Liver disease may cause you to lose your appetite and feel full too quickly after eating. This may make it hard for you to eat enough calories. Talk to your caregiver if you are having trouble eating and drinking. Care Agreement: You have the right to help plan your care. To help with this plan, you must learn about your diet. You can then discuss treatment options with your caregivers. Work with them to decide what care may be used to treat you. You always have the right to refuse treatment. Eat for health Since everything we eat must pass through the liver, special attention to nutrition and diet can help keep me healthy. Here are some tips on eating for health healthy liver, healthy you! Eat a well balanced, nutritionally adequate diet. if you enjoy foods from each of the four food groups, you will probably obtain the nutrients you need. Cut down on the amount of deep-fried and fatty foods you and your family consume. Doctors believe that the risk of gallbladder disorders (including gallstones, a liver-related disease) can be reduced by avoiding high-fat and cholesterol foods. Minimize your consumption of smoked, cured and salted foods. Taste your food before adding salt! Or try alternative seasonings in your cooking such as lemon juice, onion, vinegar, garlic, pepper, mustard, cloves, sage or thyme. MEAT, FISH, POULTRY & ALTERNATIVES PROVIDE: protein, vitamin A, iron, vitamin B12, niacin, fiber, thiamin BREADS AND CEREALS PROVIDE: carbohydrates, niacin, thiamin, iron, riboflavin, fiber FRUITS AND VEGETABLES PROVIDE: vitamin A, vitamin C, iron, fiber, folacin MILK AND MILK PRODUCTS PROVIDE: calcium, riboflavin, niacin,folacin, vitamin A, vitamin B12, vitamin D Increase your intake of high-fiber foods such as fresh fruits and vegetables, whole grain breads, rice and cereals. A high-fiber diet is especially helpful in keeping me healthy. Rich desserts, snacks and drinks are high in calories because of the amount of sweetening (and often fat) they contain. Why not munch on some fruit instead? Keep your weight close to ideal. Medical researchers have established a direct correlation between obesity and the development of gallbladder disorders. Vegetarianism and The Liver The liver has been described as a chemical workshop of the human body. All the nutrients and other substances absorbed from the intestines pass through the liver before entering into the systemic circulation. Thus the liver is vulnerable to the damage caused by a host of infections and toxic agents. Several types of viruses and alcohol are by far the commonest of these agents. The impairment of the liver function usually manifests as jaundice. Persistent infection and continuing impairment of function may be followed by death unless these changes can be controlled. The morphological changes in liver damage can manifest as fatty liver, hepatitis, cirrhosis of the liver and cancer of the liver. A well planned dietary regimen is of utmost importance in the prevention and treatment of most hepatic disorders. It has been proved beyond doubt that some of the proteins derived from animals are responsible for producing persistent symptoms related to liver disease. Thus vegetarian diet, as mentioned below, has gained momentum in the treatment of hepatic disorders. Viral Hepatitis Since there are no antiviral agents against hepatitis,rest, abstinence from alcohol and dietary modifications form the mainstay of the treatment. Most patients have nausea and lack of appetite. They should be served wit attractive and well cooked foods. Small meals served separately will be better tolerated than three large meals. A diet containing approximately 2000 kcal which can be provided by 20-25 gms fat, 80-90 gms pro teins and 400 gms carbohydrate is suitable. This requirement can be fulfilled by glucose, sugar, fruits, fruit juices, bread, cereals, vegetables, salads, jelly, jam , rice, boiled potatoes and puddings made with cereals and sugar. Though diets high in their fat content do not ultimately influence the course of the disease they are poorly tolerated by jaundiced patients. Fried food, milk and butter cause dyspepsia and should be avoided. Thus a vegetarian diet is better tolerated by the patients suffering from viral hepatitis. Cirrhosis of Liver Most of the patients of cirrhosis of liver are severely malnourished and require a high calorie and high protein diet. A high protein diet, particularly if derived from animal proteins, carries a high risk of precipitating hepatic encephalopathy. The best source of vegetarian proteins is milk, its products and Casilan. Choline present in foods like wheat germ, soyabean, peanuts and skimmed milk may prevent the formation of a fatty liver. It is also believed that cerebral disturbances due to liver damage are caused by the type of protein in the diet. Cirrhotic diet prescribed in a standard Indian books on diet and nutrition does not contain proteins derived from animal sources. A diet high in carbohydrate and proteins low in fat and fortified with vitamins would be most suitable. Thus a vegetarian diet is more suited to patients having cirrhosis of liver. Ascites In terminal stages of cirrhosis fluid accumulates in the abdominal cavity due to failure of the liver to synthetize plasma albumin. For such patients, a high protein diet which is low in sodium would be most suitable. But since these patients have no appetite, milk is the only practical diet which can supply the above requirements. Finally when the liver fails - the condition is known as hepatic encephalopathy. There is a strong incidence of animal protein intake increasing the incidence of hepatic encephalopathy. The clinical features of this syndrome are sleep disturbances, restlessness, drowsiness, impaired intellectual function, confusion and stupor progressing to coma. Significant number of these patients develop chronic encephalopathy and can be managed successfully at home. They should be given 20 gms of protein in the diet. This should mainly be derived from skimmed milk. Thus, it is very obvious that a vegetarian diet is more useful in the treatment of all liver disorders including the last stage of liver failure. Support Liver Detoxification With Your Diet Your liver plays a complex role in many critical functions in your body. A one-word summation of its task could be "detoxification." If there are nutritional deficiencies in your diet, your liver will have difficultly eliminating toxins, which will in turn increase the amount of toxins produced by your body. Toxins and your liver Toxins come from variety of sources. They come from the environment, the content of our bowels, the food we eat, the water we drink, and the air we breathe. If you are exposed to chemicals or cigarette smoke, it is your liver's job to clean up the toxins before they do damage. The liver removes toxins in three ways: It filters the blood. It neutralizes toxins by excreting fat-soluble toxins with cholesterol through making bile. It breaks down toxins with enzymes in a two-step process usually referred to as phase I and phase II detoxification. A good diet helps your liver detoxify To support proper liver function, it is important to eat a healthy diet that includes a variety of vegetables, which provide a wide range of essential nutrients. Your liver needs these nutrients to perform its duties. Some of the best things you can do for your liver include: Eat a high-fiber diet. Fiber binds to the bile in the large intestines, which helps to transport it out of the body. This is one of the ways the body eliminates fat-soluble toxins from the body. Include variety in your diet. Eat a wide variety of nutrient-rich foods, including foods high in antioxidants (vitamin C, beta carotene and vitamin E) and high in B vitamins, calcium, and trace minerals to protect the liver from damage and help it do its job. Watch your B vitamins. Make sure to get enough choline, betaine, methionine, vitamin B6, folic acid and vitamin B12. These special nutritional factors are needed to promote liver decongestion, improve liver function and metabolize fat. Use a medically supervised fast to aid in detoxification. A fast can quickly increase elimination of waste and enhance your body's healing processes. Fasting is not right for everyone, however; talk to your doctor to learn what fast is appropriate for you. Important nutrients for your liver A diet high in fiber includes a wide variety of plant-based foods. The best way to increase fiber is to eat more vegetables, beans and fruit. Foods that contain vitamins C and E are important as antioxidants to protect and treat a damaged liver. B vitamins are often depleted when the liver is overworked from alcohol consumption or toxic exposure. Methionine and cysteine are sulfur-containing proteins that are known to protect the liver and aid in converting fat-soluble toxins to water-soluble substances that can be eliminated through the urine. Choline is needed to metabolize fats in the body. Foods that contain these vitamins include: Vitamin C. Rose hips, kale, parsley, collard greens, mustard greens, cauliflower, red cabbage, strawberries, papaya, spinach, kiwi fruit, citrus fruits, asparagus, mangos, peppers, broccoli, and Brussels sprouts. Vitamin E. Almonds, filberts, sunflower seeds, avocados, asparagus, walnuts, tomatoes, whole grains, and green leafy vegetables. B-complex. Nutritional yeast, sunflower seeds, almonds, peanuts, pine nuts, sesame seeds, buckwheat, wild rice, and brown rice. Methionine and cysteine. Egg yolks, red peppers, garlic, onions, broccoli, Brussels sprouts, sesame seeds, whole grains and beans. Choline. Soybeans, egg yolks, nutritional yeast, fish, peanuts, cauliflower, lettuce, cabbage, lentils, chick peas and brown rice. Making specific dietary changes to aid your liver in detoxification can be simple. Eating a wide variety of organic vegetables, fruits, seeds, nuts, beans and whole grains gives your body the fiber and the nutrients it needs to protect and support healthy liver function.

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