LD Flashcards

Question

ENERGY REQUIREMENTS: LIVER DISEASE BMI >30

Answer 1

ENERGY REQUIREMENTS: LIVER DISEASE BMI >30 * Mifflin St Jeor + PAL

Answer 2

ENERGY REQUIREMENTS:Liver cirrhosis all causes (BMI18.5-29.9): * 22kcal/kg+ PAL (19-27)

Answer 3

ENERGY REQUIREMENTS: ARLD with cirrhosis (BMI18.5-29.9): * 28kcal/kg+ PAL (27-29)

Answer 4

ENERGY REQUIREMENTS:ARLD non abstinent steatosis/fibrosis (BMI18.5-29.9): * 27kcal/kg+ PAL (26-27)

Answer 5

ENERGY REQUIREMENTS: Viral ACUTE hepatitis (BMI18.5-29.9): * 27kcal/kg+PAL (26-27)

Answer 6

ENERGY REQUIREMENTS: Viral CHRONIC hepatitis (BMI18.5-29.9): * 21kcal/kg+PAL (19-22)

Answer 7

ENERGY REQUIREMENTS: Hepatocellular carcinoma (BMI18.5-29.9): * 23kcal/kg+PAL (22-25)

Answer 8

ENERGY REQUIREMENTS: Other liver conditions (BMI18.5-29.9): * 20-25 kcal/kg + PAL

Answer 9

In severe alcoholic steatohepatitis <21.5kcal/day is associated with worst outcomes (Moreno et al., 2016)

Answer 10

Caution should be used when using MIFFLIN because: * illneses were not considered during its creation. The population it is based on are healthy subjects * population were primarily caucasian * doesn't account for fat/muscle composition * adjusted body weight recommended to avoid overestimation of requirements however caution to be used when individual is acutely unwell

Answer 11

Advice for liver disease prevention: * Healthy balanced diet * Healthy weight * Good diabetes control * Physical activity * Alcohol within government guidelines

Answer 12

**ESPEN guidance for: Metabolic dysfunction–associated steatotic liver disease (MASLD) without cirrhosis:** * Exercise and diet can treat MASLD - **diet + exercise is the most effective approach** * Obese/overweight: **Weight loss, 7-10% target** * Obese/overwit: hypoclaoric diet irrespective of macronutrient content * No single diet better than others: should be individualised for each person * Normal wt: increased physical activity to improve insulin resistance & steatosis (not based on evidence implied from overwt/obese) * Normal wt: reduction in fructose rich drinks (no evidence cited) * **Mediterranean diet **without alcohol: improve steatosis & insulin sensitivity * **Identify and treat co-morbidities** – coeliac, diabetes as these contribute to poor liver function * **Vitamin E** supplementation: NASH and **probiotics + prebiotics** may be helpful: LFT improvement * Not enough evidence for omega-3 supplementation

Answer 13

**Study cited by ESPEN PROBIOTIC use for MASLD without cirrhosis:** * An Iranian double blind RCT of 72 patients aged 23-63. * Compared the use of yoghurt enriched with lactoacidophilus La 5 & Bifidobacterium Lactis B12 with a conventional yoghurt. * The intervention group had statistically significant decreases in liver function markers, total cholesterol & LDL. An increased intake of protein was also reported. * The risk of bias in this trial was reduced due to the double blinding and use of same packaging and branding of the yoghurts given to participants. * However, the diet histories of participants were only for 3 days at the beginning and end of the study provided as a 24H recall which makes it vulnerable to error. * Also, by only analysing the diet on those 6 days out of 8 weeks, it is not clear whether the observed changes were due to intake of the yoghurt. * Small study

Answer 14

Consequences of malnutrition * Increased mortality * Infections * More days in ICU * More days on a ventilator * More days in hospital * Delayed wound healing * Encephalopathy * Variceal bleeding * Ascites * Worse quality of life * Osteoporosis

Answer 15

Biochemistry associated with liver disease * Alanine aminotransferase (ALT) ↑ * Aspartate aminotransferase (AST) ↑ * Alkaline phosphatase (ALP) ↑ * y-Glutamyltransferase (GGT) ↑ * Bilirubin ↑ * Albumin ↓ * Blood clotting tests: Prothrombin time (PT) ↑, International normalised ratio (INR) ↑ * CRP ↑

Answer 16

UKELD- United Kingdom End Stage Liver Disease & MELD- The Model of End Stage Liver Disease: * Scoring system used to predict mortality among patients waiting for a liver transplant * A UKELD score of 49 or more is required for liver transplant unless there is another indication, such as hepatocellular carcinoma. * Score of 49 or more: possible benefits of a transplant are estimated to be greater than the possible risks.

Answer 17

TIPS (Transjugular intrahepatic portosystemic shunt): * Placement of a stent in the blood vessels which feed and drain the liver. * Performed if there is a block of flow of blood through the liver, leading to high pressure. * The high blood pressure can lead to varices. * Risk of worsening hepatic encephalopathy

Answer 18

Liver resection: * Treatment for liver cancer. * Removal of a section of the liver where a tumour is growing. * The part of the liver removed will grow back after a few weeks. **Nutrition Considerations:** Good nutrition post surgery Low phosphate as liver regenerates

Answer 19

Nutrition Considerations for a liver resection: * Good nutrition post surgery * Low phosphate as liver regenerates ???

Answer 20

Key Medications used in Liver Disease: * Diuretics: Spironolactone (K sparing), Furosemide (K/Mg wasting) * Laxatives: Lactulose - reduces ammonia production + absorption, Senna or Movicol * Beta blockers: Propanolol or Carvedilol * Antibiotics: Ciprofloxacin, Tazocin, Rifaximin - treats HE, Rifampicin - to treat itch * Steroids: Prednisolone, likely to be on bone protection (Vit D/Ca) * Antiemetics: Cyclizine, Metoclopramide - prokinetic, Ondansetron * Other: Cholesytramine - to treat itch, Pancreatic Enzyme Replacement Therapy (PERT) - Creon, Pancrex, Nutrizym, Thiamine , Vitamin B compound strong, Ursodeoxycholic acid (PBC), Vitamin D +/- calcium, Human Albumin Solution (HAS) Penicillamine / Trientine - Wilson’s Disease Antiviral e.g. tenofovir (hep B)

Answer 21

Factors that contribute to malnutrition in Liver Disease: * Decreased energy intake: ascites, salt restriction, micronutrients deficiency, loss of appetite despite increased ghrelin, portal HTN * Malabsorption & nutritional losses: Impaired bile acid production, PEI, SIBO, Paracentesis protein losses, medication * Altered protein, fat and CHO metabolism: Decreased BCAAs /Increases AAAs, Insulin resistance, Increased protein breakdown, decreased protein sythesis, inreased ketogenesis, decreased glucogenolysis> accelerated state of starvation> increased gluconeogenesis

Answer 22

Pathogensis of malnutrition in liver cirrhosis: Alcohol/Fasting periods lead to: * gut microbiome dysbiosis * altered nutrient metabolism * hypermetabolism * malabsorption * hormones * inflammation

Answer 23

Cirrhotic livers have **impaired** glycogen synthesis

Answer 24

Decompensated livers **struggle** to make enough glycogen. **~3h** worth

Answer 25

Frailty: * A biological syndrome of decreased reserve and resistance to stressors, resulting from cumulative decline across multiple physiological systems, and causing vulnerability to adverse outcomes”

Answer 26

Sarcopenia: Low muscle mass & low strength/low physical performance

Answer 27

Components of frailty: * Sarcopenia * Malnutrition * Functional decline * Deconditioned/ poor fitness * Impaired cognition

Answer 28

It is important to remember that low muscle mass is possible at any BMI

Answer 29

Cachexia: Cachexia is a complex syndrome associated with an underlying illness, causing ongoing weight loss, muscle loss that is not entirely reversed with nutritional supplementation. * Characterized by: - loss of skeletal muscle - loss of fat - loss of muscle strenght - fatigue - anorexia - low fat free mass index - abnormal biochemistry

Answer 30

Diagnosis of Cachexia (3 out of 5): - Wt loss of at least 5% in 12m or less - Decreased muscle strength - Fatigue - Anorexia - Low fat free mass index - Abnormal biochemistry: Increased inflammatory markers (CRP, IL-6), Anaemia (Hb<12g/dL), Low serum albumin(<3.2g/dL)

Answer 31

Considerations for ANTHROPOMETRIC measures in liver disease: * BMI & weight may be unreliable due to ascites * Upper arm anthropometry: TSF, MUAC, MAC might be useful * MUAC tends not to be affected by oedema

Answer 32

A prospective cohort study of patients with decompensated cirrhosis found: * Mid arm circumference may be an indicator of nutritional status * A low MAC predicted mortality independently

Answer 33

Estimating dry weight: * Dry weight= wet weight- estimated weight of ascites or oedema * Advised to consider patient's weight history prior to ascites/oedema * Compare wt before and after drainage but don't rely on wt post-drainage (fluid may still be present) * Estimation of dry wt: use Mendenhall (1992) or EASL

Answer 34

Mendenhall (1992)/ Madden & Wicks 1994 (PENG) Ascites & Oedema estimation: **Ascites** * Mild: 2.2kg * Moderate: 6kg * Severe: 14kg **Oedema** * Mild: 1kg * Moderate: 5kg * Severe: 10kg Limitations: * Unable to access paper to judge if based on evidence * Patients tend to have more fluid than estimated. * From 1992: how relevant to current population * Based on visual opinion of fluid retention, subjective * There will be great variability between patients. Very unlikely all will have same amount of fluid.

Answer 35

EASL (2019) Ascites & Oedema estimation **Ascites** * Mild: 5% * Moderate: 10% * Severe: 15% **Oedema** * 5% Advantages: * In comparison to Mendenhall/ Madden & Wicks 1994 (PENG) this takes into account the patient's own body weight and is more individualised as it is a percentage instead of just a value Limitations: * Not based on evidence: cited sources are just others who use the values * Not validated * How can a general percentage of fluid be assumed by grading of oedema/ascites? * Not based on evidence: cited sources are just others who use the values

Answer 36

LIVER disease dry weight estimation my choices: * Wt history, pre & post paracentesis weights, scans preferred to estimate dry wt * Otherwise: EASL instead of Mendenhall (PENG, 1991) * Assumed that Mendenhall is based on a study however, unable to locate. * Mendenhall is just based on values, less individualised than EASL where percentages allow for different values based on the patient's dry weight, more individual * However: EASL's values are not validated, nor are they based on evidence they are based on what other clinicians do. How likely is it that the values they suggest are reflective of different grades of ascites and of oedema?

Answer 37

Biochemistry markers for Liver Disease: * Sodium * Potassium * Magnesium * Phosphate * Adjusted Calcium * Creatinine, urea and eGFR/AKI stage * Liver function tests – bilirubin, alkaline phosphatase (ALP), alanine transaminase (ALT), albumin * (Ammonia): doesn't tell much likely to be high * Blood glucose * HbA1c * CRP

Answer 38

Clinical Considerations for LD: * Aetiology of liver disease * Stage of liver disease * Decompensated or compensated? * Refeeding risk * Admission reason * Current medical treatment * Past medical history * Nausea and vomiting * Stool symptoms - malabsorption?

Answer 39

Stool symptoms to consider: * Frequency * Consistency * Colour * Signs of malabsorption: smell, oily, pale, orange, yellow, floaty, undigested food Think about: * What is normal for patient (before illness) * Medication, e.g. laxatives, antibiotics, iron supplement, opioids * Risk factors for malabsorption, e.g. alcohol related liver disease and pancreatic enzyme insufficiency, PBC/PSC * Any dietary adjustments needed?

Answer 40

Dietary considerations of LD: * Refeeding risk? * CHO & Pro: Frequency (most important) & QTY * Fluid * Fat * Food groups * Alcohol * Salt * Changes to appetite? * Eating pattern? * Overall adequacy * Restrictions? * Allergies/intolerances * Nutritional requirements vs intake * Eating pattern (>3H with no intake and bedtime snack?) * Contigency plans when not feeling well?

Answer 41

Vitamin & mineral levels: Liver Disease * Risk factors for deficiencies, e.g. cause of liver disease, co-morbidities & treatment – influence on micronutrient absorption, metabolism or requirements. * Identify deficiencies with available blood test results * Look for overt signs of deficiency such as fatigue, impairment in wound healing * Check for potential deficient intake * Liaise with medical team for supplementation as sometimes this will be due to a medical cause i.e. variceal bleeding so this will be medically corrected Common deficiencies: B vitamins Fat soluble vitamins, including vitamin D Iron deficiency anaemia Zinc, selenium, copper

Answer 42

Protein Energy Malnutrition exists in 80-100% of patients with decompensated cirrhosis (PENG)

Answer 43

Main reasons for malnutrition in liver disease: * decreased dietary intake * poor quality diet * impaired postprandial glucose storage * increased energy expenditure * altered substrate demands * maldigestion and malabsorption

Answer 44

How altered metabolism causes malnutrition in liver disease: * Glycogen stores are small in comparison to healthy subjects * Gluconeogenesis from body protein provides glucose for short-term energy needs: leads to muscle wasting

Answer 45

Novel approach for ascites estimation: abdominal girth may be a novel approach to the estimation of dry weight in patients with ascites. 1. Lamarti & Hickson conducted a study in 24 white british, liver disease patients with ascites. 2. A statistically significant relationship was found between the weight of the ascites and pre-paracentesis girth, 3. an equation was formulated based on this. 4. This method is not yet validated and will need to be assessed in a higher number of patients & with other ethnicities 5. however it was found that the values listed in PENG may underestimate the amount of ascites fluid in patients. 6. A validated equation would allow for greater individuality.

Answer 46

50g CHO late evening snack is beneficial in liver disease because: * increases CHO oxidation * decreases lipid & protein oxidation rate * improves N balance and reduces fasting periods overnight

Answer 47

Eating Patterns: Liver Disease * 50g CHO bedtime snack * "Cirrhotic Eating Pattern"

Answer 48

Patients with **cirrhosis** enter the starved state quicker than healthy controls.

Answer 49

Examples of 50g CHO snacks: * 300ml milk & 3 plain biscuits * ONS volume equivalent to 50g CHO * 5 plain biscuits * 2 thick slices toast w jam

Answer 50

The "Cirrhotic" Eating Pattern * Helps to reduce accelerated starvation due reduced glycogen stores * At least 3-4 portions of protein per day * Protein source with each meal * Protein included with as many snacks as possible * Protein rich drinks * Reduces fasting gluconeogenesis & muscle catabolism

Answer 51

50g bedtime CHO snack * reduces amount of gluconeogenesis and muscle breakdown at night due to reduced glycogen stores * increases CHO oxidation * decreases lipid & protein oxidation rate * improves N balance and reduces fasting periods overnight * Patients with early satiety/poor appetite may find carbohydrate dense options more manageable * Starchy is better but low GI is best * Ideally include a good source of protein too * Mindful of diabetes – more starchy snacks, monitor blood glucose: LOW GI foods

Answer 52

Evidence for "Cirrhotic" Eating Pattern (Owen et al., 1983) * Various studies indicate that the cirrhotic eating pattern is beneficial * A study investigating energy metabolism in patients with alcoholic cirrhosis using indirect calorimetry and tracer analysis found that: * Despite normal basal metabolic rates after an overnight fast, the fuels oxidized by cirrhotic patients resembled those of healthy individuals after 36-72 hours of starvation, * There was a higher reliance on fat and lower use of carbohydrates. * These findings suggest that patients with alcoholic cirrhosis enter a starvation-like catabolic state more rapidly, potentially contributing to cachexia.

Answer 53

Evidence for 50g CHO snack (Tsien et al., 2012) * Systematic review to evaluate the efficacy of a late evening snack (LES) to improve substrate utilization, nutritional indices (including increase in skeletal muscle mass), and clinical outcomes in cirrhosis. Findings: * LES: the change in substrate utilization from glucose to fat is delayed * Long-term LES = increase in lean mass with >50g CHO * Can be food or ONS * LES may be valuable in early compensated cirrhosis to preserve existing skeletal muscle mass.

Answer 54

Cirrhosis is a state of **anabolic** resistance

Answer 55

50g bedtime CHO snack pros and cons (Tsien et al., 2012) Pros * Cheap * Easy * Increases glucose oxidation and reduces fat & protein oxidation Cons * Higher amounts may be needed to have a difference on skeletal mass * May exacerbate acid reflux * May cause sleep disturbances * May worsen glucose intolerance * Poor compliance as outpatients

Answer 56

We know that when someone has liver cirrhosis, not eating from evening meal until breakfast is like someone with a healthy liver not eating for **2-3** days!

Answer 57

Advice for malnourished: * High energy food and drink * Little and often * Add extra to the small portions managed * Nourishing drinks * High protein? * Food fortification?

Answer 58

Gastrostomies are contrainindicated in liver disease because of ascites

Answer 59

Nutrition support for LD * Food * Oral nutritional supplements * Nasogastric feeding * Nasojejunal feeding * Gastrostomies are contraindicated * Parenteral nutrition

Answer 60

Nutritional intervention: Liver disease without malnutrition or obesity (Community/Non specific LD) * Individually tailored – comorbidities, risk of malnutrition, patient-preferences & desires **Cirrhosis** * Balanced diet with regular meals * Good & frequent sources of protein * Physical activity * ?Add in bedtime 50g CHO snack +/- snacks between meals only if needed * Achieve a cirrhotic eating pattern with healthy snacks – yogurt, fruit, whole nuts * Prevention of malnutrition, sarcopenia and frailty **Fibrosis & Steatosis** * Remove the cause of liver damage if diet-related * Alcohol abstinence * Healthy balanced diet * Good diabetes control

Answer 61

Rapid weight loss in obese patients with compensated cirrhosis can cause the liver to decompensate

Answer 62

Branched chain amino acids: essential nutrients that help support muscle metabolism and are important for building muscle tissue protein.

Answer 63

Formulas for NS in LD * High protein * High energy * Low volume (concentrated) * Patient preference and tolerance * Reduced fat * Medium chain triglycerides * Feed for improved tolerance

Answer 64

Liver disease with obesity

Answer 65

Hepatic encephalopathy: a condition that occurs when the liver is too diseased or damaged to properly process ammonia, leading to a buildup of ammonia in blood that travels to the brain

Answer 66

Protein previously restricted in hepatic encephalopathy because the condition is caused by build of ammonia that travels to the brain & ammonia is produced by dietary proteins

Answer 67

Hepatic encephalopathy & diet * Do not protein restrict * Cordoba et al (2004) - no difference in outcome for hepatic encephalopathy for patients on low protein and normal protein diets. Low protein diet showed greater catabolism and muscle loss * Skeletal muscles contribute to ammonia metabolism … if a patient has muscle wasting, the skeletal muscles have less capacity to metabolise ammonia, worsening HE * Meet energy and protein requirements to reduce catabolism * Continuous protein to keep ammonia levels steady * Patients with severe HE may be protein intolerant * Severe HE & high ammonia, not resolving: may protein restrict to a minimum of 1g/kg for a short period and monitor HE. No improvements after a short period (1-2 weeks): protein restriction would be lifted. Improvement: protein would be reintroduced gradually to tolerance. * BCAAs could be an option for patients with protein intolerance and HE but this is not yet available in the UK,

Answer 68

For patients with ascites: * Restrict to ~5 g (~80 mmol sodium) per day * Individual assessment and support * Avoid adding salt at the table * Reduce salt in cooking, e.g. lower salt stock, use herbs, garlic and lemon to add flavour. * Avoid high salt foods * Avoid salt alternatives, e.g. LoSalt, PanSalt, Solo. * Ensure the restriction is not excessive * Food label education

Answer 69

Fat restriction LD * For symptomatic control * More likely to be required in biliary conditions * Not appropriate for treating Pancreatic Enzyme Insufficiency (PEI)

Answer 70

Diabetes management LD * Monitor blood glucose. Good control is important. Perfect control may not be possible. * HbA1c may not be an accurate measure of glycaemic control (neither accurate nor reliable in patients with cirrhosis due to the various kinds of anemia common in liver disease) * Complex carbohydrates, wholegrain if appropriate * Low GI foods * Small carbohydrate snacks between meals, with fat and protein * If supplements are needed consider their effect on blood glucose * Collaborate with diabetes specialists. Diabetes medication may need to be adjusted to enable a cirrhotic eating pattern

Answer 71

HbA1c is neither accurate nor reliable in patients with cirrhosis due to the various kinds of anemia common in liver disease (Sehrawat, 2018)

Answer 72

Liver Disease nutrition before transplant * Good nutrition support to optimise for major surgery * Treat malnutrition * Prevent/minimise decline in nutritional status whilst waiting * For some patients, controlled weight loss may be required to reduce the risk of the surgery * Gradual weight loss * Monitoring for malnutrition and sarcopenia

Answer 73

Liver Disease nutrition after transplant * Some patients are tube fed post-transplant. * Patients are gradually upgraded from sips water > normal diet. * Short-term: High energy and protein diet to meet elevated nutrition requirements post-transplant, treat malnutrition and aid recovery. * Long-term these patients are at increased risk of weight gain and cardiovascular disease, so when nutritional status is (almost) recovered they should be supported to stop ONS and transition to healthy eating. * Exercise is important, walking is great! * Due to being on immunosuppressant medication, patients are at higher risk of food-borne infections. Advice is given on foods to avoid reduce this risk. * Certain foods interfere with immunosuppression. Advice is given on these. * Avoid soft cheeses made from unpasteurized milk such as blue-veined cheeses, Brie, Camembert, feta, goat cheese, queso fresco/blanco

Answer 74

Dietary advice following liver transplant with immunosuppressant use * AVOID grapefruit, pomegranate, pomelo, blood orange, and black licorice: increase amount of medication available Ensure all food is properly cooked  Do NOT eat any raw or undercooked meats, proteins, dairy or egg products; this includes sushi, raw cookie dough/cake batter, over-easy eggs  Reheat all leftovers  Microwave or cook all lunch meats  Avoid buffets  Do not use wooden cutting boards  Use separate cutting boards/utensils for raw meats  Make sure all products are pasteurized  Wash all fruits and vegetables thoroughly  Only eat at safe, clean, trusted restaurants  Do not eat food that has been sitting out or exposed to direct sunlight, such as at picnics

Answer 75

**Alcohol related liver disease** * Refeeding risk increased by alcohol * Do not always lose weight due to ‘empty calories’ from alcohol * Likely to require a broad spectrum multivitamin mineral with trace until diet adequate **Wilson’s Disease** * Dietary copper restriction may be required - often needs to be stricter in the early period of treatment **Haemochromatosis** * Consider iron restriction / avoidance of vit C products * Standard feeds/ONS are used in end stage liver disease. **Ascites without cirrhosis** * No added salt diet * High protein likely if having paracentesis * Cirrhotic eating pattern not needed if good liver function

LD Flashcards

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