NutritionalIssuesInAdvancedLiverDisease

CorrieClark,RDN,LD

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•Vitaminandmineraldeficiencies•Osteoporosis

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.