ESLD Flashcards
MASLD/MASH (Metabolic dysfunction associated steatotic liver disease/steatohepatitis)
Clinical presentation :
Sx’s?
Labs?
Liver biopsy?
Any drugs yet? What can be ways pt’s can combat this?
Mostly asx’s !
+/- Fatigue and Upper abd pain
-AST/ALT can be normal or abnormal
- Steatosis, lobular inflammation, ballooning
No drugs approved. Weight loss, diet and exercise
Comorbid conditions associated with MASLD?
Obesity, T2DM, HTN, DLD, Obstructive sleep apnea, CVD (Important cause of death in MASLD pt’s) , CKD
NALFD (MASLD) in Lean Individuals
-Occurance in pt’s with which BMI?
-More common in pt’s of which heritage?
-What would be appropriate for these pt’s?
<25 or <23 in asians
hispanic, asian
weight loss not appropriate but dietary modifications and exercise!
Lifestyle Modifications For management of NAFLD (MASLD) GENERAL
Weight loss of ?
identify?
Get ___
Maintain ___
Specifically incorporate?
Specifically avoid?
> 5-10% of initial body weight
-psychological barriers to lifestyle change and physical barriers to lifestyle change
-sufficient sleep
-weight loss
Water and zero calorie bevs in place of sugary beverages , more active lifestyle, portion controll, limit alc, coffee, use stairs, wear pedometer
late night eating, sugary beverages and deserts
DIET
restriction of calorie intake by?
Carb amount?
Replace calories with ?
Avoid ?
what should pt’s specifically avoid?
500-1000 kcal daily (1200-1500 kcal daily if ur <115 kg, 1500-1800 kcal daily if ur >115kg)
low carb diet (<40-45%) (veggies 3-5 servings, fruits 2-4 servings)
PUFA, MUFA (EVOO 60 mL daily, nuts, avocado, olives, oily fish like salmon and tuna)
Trans fat, limit saturated fats to 7-10% (incorp olive oil or olives)
High calorie foods, high sugar bevs, simple carbs and high fructose corn syrup, herbal supps and non prescribed vitamins)
EXERCISE
Increase physical activity as tolerated based on medical conditions
Describe some incorporations and what to avoid
Cardiovascular training 5x per week , resistance training >/= 2x per week
150-300 min weekly at mod intensity or 75-100 min weekly at vigorous intensity
AVOID sedentary lifestyle
What’s the cornerstone?
NO FDA approved tx
What can be used for T2D/obseity in pt’s with NASH or MASH?
WHat can be considered for NASH pt’s with T2d ?
DIET AND EXERCISE
Semaglutide
Pioglitazone
CIRRHOSIS : Child Turcotte Pugh Classification
Clinical and Lab criteria?
State the diff between Class A and Class C
Encephalopathy, ascites, bilirubin, albumin, prothrombin time
Class A = 5-6 pts, 5-10% chance of dying in next five yrs! relatively stable
Class C = 10-15 pts , 75% mortality in the next year
Compensated Vs DECompensated Cirrhosis
Compensated ? Sx’s? Death at 1 yr?
Decompensated sx’s? death at 1 yr?
Comp : asx’s +/- varices
1-3%
Stage 1 and 2
Decomp : Development of jaundice, ascites, variceal hemmorhage, HE, or CTP score 10-15 class C
20%-57%
Stage 3 and 4
Overall goals to Manage Cirrhosis/ESLD
-protect the __ from harm
-Discontinue ____
Monitor ____
Avoid _____
Maintain vigilence for comps of cirrhosis
screen for ____
Screen for ____ every ___
Refer for ___
liver
harmful meds
BP
alc,nsaids, herbal meds, raw shellfish
esoph varices
HCC, 6 months
liver transplant if needed
ASCITES
-Most common comp of cirrhosis
-Clinically evident when ???
Goals of therapy
Decr __,___,____
Prevent complications such as?
Weight loss of ?
Urine output should exceed fluid intake by ____
Considerations
How should u remove the fluid? What should u be careful of when u over diurese?
> 1500 mL fluid has accumulated
abd discomfort, back pain ,difficulty ambulating
respiratory distress, spont bacterial peritonitis, hernias, pleural effusions
0.5-1kg/day = 0.5-1L/day
300-1000 mL/day
Gradual and cautious removal of fluid
-Acid base imbalance, electrolyte imbalance (HYPOkalemia), intravascular volume depletion
ASCITES : Diuretic Therapy
What drug combo and dose?
Can incr simultaneously every ?
Maintain a ___ ratio
max doses?
furosemide added to ?
Spironolactone 100 mg PO daily + Furosemide 40 mg PO daily
3-5 days to achieve adequate diuresis and maintain normal Serum K
100:40 ratio
max = 400 mg spiro, 160 mg furo
minimize risk of hyperkalemia and enhance diuresis
Refractory ascites
-Unresponsive to sodium restriction max dose spiro+furo
50% mortality in six months
-recurs rapidly after paracentesis
WHat’s the alt therapy ?
Midodrine 7.5 mg PO TID
Paracentesis
-Indicated in ?
Risk of?
What’s the range of fluid u can remove?
What’s given for large volume?
REFRACTORY ascites
-Infection or hypovolemic shock
1L to 10L
Albumin (given for >5L)
ASCITES NON PHARM
Protein ?
Sodium restriction ?
Fluid restriction ?
Nsaids?
Ace or arbs?
Alcohol?
1-1.5 gm/kg/day
2g/day
only if Na<120
avoid!
avoid
DC
