Nutrition Management of End- Stage Liver Failure

Transcription

1 Nutrition Management of End- Stage Liver Failure Krystel Ouaijan, RDN, MSc Nutrition Support Dietitian in Saint George Hospital UMC PhD in University of Geneva

2 Just few questions 27b8f5bc58ebf0c94a793/d2b52d9231b1/edit Use your phone and vote! and use code This will be our outline in addition to Probiotics!

3 Challenges on the way Practical: difficulties in assessing body composition and inadequacy of equations predicting energy expenditure Patient-related: poor appetite Pathophysiological consequences of liver disease: altered macronutrient metabolism, energy expenditure with disease progression There is little or no evidence to support many of the routine clinical approach! Mouzaki et al. Journal of Parenteral and Enteral Nutrition 2014; 38 (6)

4 Malnutrition is very common 60% 60% 50% 40% 30% 20% 10% 0% 20% Prevalence Compensated cirrhosis Advanced disease Italian Multicentre Cooperative Project on Nutrition in Liver Cirrhosis. Journal of Hepatology 1994; 21:

5 Malnutrition and survival Groups based on MUMAC percentiles Alberino et al. Nutrition 2001;17:

6 Factors contributing to malnutrition Cholestasis and portal hypertension Esophageal varices Glucose metabolism Systemic vasodilation and decrased clearance of proinflammatory cytokines Bemeur et al. Journal of Nutrition and Metabolism 2010;

7 Nutrition Assessment Subjective Global Assessment 1. Clinical information through history taking 2. Recent weight change and PO intake change 3. Physical examination The use of anthropometric parameters which are not affected by the presence of ascites or peripheral edema Bemeur et al. Journal of Nutrition and Metabolism 2010;

8 Nutrition Assessment Two parameters used are: 1. Mid-arm muscle circumference MAMC 2. Triceps skinfold thickness TST Diagnosis of malnutrition is established by values of MAMC and/or TST below 5 th percentile in patients aged years or below 10 th percentile in patients aged over 74 years Bemeur et al. Journal of Nutrition and Metabolism 2010;

9 Nutrition Assessment One study (>1000 patients) validated the use of BMI against MAMC and TST in cirrhotic patients with different levels of ascites. BMI <22 with no ascites BMI <23 with mild ascites BMI <25 with tense ascites Krystel Ouaijan - Dubai Campillo et al. Gastroenterology Clinical Biology 2006; 30:

10 Nutrition Assessment Algorithm A global assessment scheme: a simple, reproducible, valid, and predictive method One note on Assessing PO intake: May be inaccurate in those with poor memory or encephalopathy Morgan et al. Hepatology 2006; 44:

11 Handgrip Strength 70% 60% 50% 40% 30% 20% 28% % 63% SGA PNI HG Major complicati ons HG PNI SGA PCM 65. 5% PCM % PCM 33. 3% PCM % PCM 35. 7% PCM % 10% 0% Cirrhotic patients HG was the only technique that predicted a significant incidence of major complications in 1 year in undernourished cirrhotic patients Alvares et al. Nutrition 2005;21 (2):

12 Confused? According to ESPEN, simple bedside methods such as SGA and anthropometric measurements are reliable in assessing the nutritional status of cirrhotic patients. Most important is to be aware of malnutrition! Plauth et al. Clinical Nutrition 2006; 25:

13 Ammonia metabolism and malnutrition Bemeur et al. Journal of Nutrition and Metabolism 2010; c

14 Dogma of Hepatic Encephalopathy Restriction of dietary protein was long considered However a mainstay studies have in shown the management that protein of liver disease and HE. restriction in these patients has no impact on encephalopathy grade and that it may even Protein restriction (0 40g protein/day) was shown worsen their nutritional status to decrease encephalopathy grade in patients following surgical creation of a portal-systemic shunt. This was later extended to include all patients with cirrhosis who developed encephalopathy. Mullen et al. Journal of Hepatology 2004; 41 (1):

15 Most important study Patients with encephalopathy randomized to two diets in hospital: 1.2g/kg protein Low-protein diet with protein intake advancing gradually This study remains unique in that it was the first to examine the role of dietary protein load on encephalopathy with other variables controlled. It changed conventional wisdom regarding protein intake in encephalopathic patients. Cordoba et al. Journal of Hepatology 2004; 41 (1):

16 Most important study Cordoba et al. Journal of Hepatology 2004; 41 (1):

17 Recommendations Always use dry weight ESPEN: 1-1.5g/kg protein/day International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus: Limitations: g/kg protein/day 20 patients ASPEN: no mention of protein requirements but recommends standard Not a enteral mentioning formula the type of protein American Association for the Study of Liver Diseases: g/kg protein/day American College of Gastroenterology Practice Guidelines on Hepatic Encephalopathy: acute encephalopathy, 0.5 g/kg/day with subsequent progressive increase to g/kg/day More advanced nutrition assessment tools

18 Vegetable versus animal protein Vegetable is suggested by all societies to be better tolerated than animal proteins. Old trials suggest 30-40g of vegetable Let s review some metabolism! proteins/day to achieve the protein target. Why? 1. Higher content of BCAAs 2. Influence on intestinal transit (fiber) Bemeur et al. Journal of Nutrition and Metabolism 2010; c

19 BCAA/AAA BCAAs are the AAs that are not metabolized in the liver Liver clearance of AAA is depressed Serum BCAA levels fall and AAA levels increase change in plasma molar ratio of BCAA to AAA AAA cross the blood-brain barriers generation of false neurotransmitters. The ratio may contribute to development of hepatic encephalopathy. Johnson et al. Nutrition in Clinical Practice 2013; 28 (1):

20 Modification of protein in the diet 153 cirrhotic patients with overt HE followed for 14 days Modified HPHC: 30 kcal/kg/day and 1.2g proteins/kg/day Diet based on better-tolerated vegetable and milkderived proteins Child-Pugh score: method to assess severity of prognosis of liver disease: Albumin, bilirubin, ascites, encephalopathy, INR Gheorghe et al. Romanian Journal of Gastroenterology 2005; 14 (3):

21 Modification of protein in the diet Series 1 Series Blood Ammonia Levels Child-Pugh Score Gheorghe et al. Romanian Journal of Gastroenterology 2005; 14 (3):

22 What about supplementing BCAAs? Low plasma BCAAs in liver disease: Portal-system shunting decreases plasma concentration Hyperammonemia increases utilization BCAAs supplementation facilitates ammonia detoxification by supporting muscle glutamine synthesis. Clinical trials of BCAAs in the treatment of have yielded inconsistent findings Johnson et al. Nutrition in Clinical Practice 2013; 28 (1):

23 Let s see a meta-analysis 16 RCTs on BCAA versus control interventions No effect on mortality but on HE This effect was lessened when controlling for lactulose and severity of type of HE Krystel Ouaijan Gluud - Dubai et al. -The 2018 Cochrane Database of Systematic Reviews 2015; 9: 1-89.

24 Time of supplementation of BCAAs Cross-over study on 12 patients for 3 weeks 1.3g protein/kg/d Granules of BCAA (daytime versus nocturnal) Krystel Ouaijan Fukushima - Dubai et al. - Journal 2018 of Parenteral and Enteral Nutrition 2003; 27 (5):

25 Time of supplementation of BCAAs Long term for 3 months Daytime BCAAs may be used primarily as calories whereas nocturnal BCAAs may be used for protein synthesis Bedtime snacks are encouraged to avoid gluconeogenesis since glycolysis is impaired Krystel Ouaijan Fukushima - Dubai et al. - Journal 2018 of Parenteral and Enteral Nutrition 2003; 27 (5):

26 Limitations of use of BCAAs Not always available Poor palatability Expensive Low compliance Johnson et al. Nutrition in Clinical Practice 2013; 28 (1):

27 Another more acceptable supplement Prebiotic Probiotic Synbiotic Johnson et al. Nutrition in Clinical Practice 2013; 28 (1):

28 Probiotic and synbiotics Cirrhosis leads to progressive changes in gut microbiome and alteration of microflora. Increased gut production of ammonia Administration of lactulose and neomycine. What about another supportive alternative? Increased gut production of endotoxins Endotoxins propagate systemic inflammation because of lack of detoxification by the liver Amodio et al. Current Opinion in Clinical Nutrition and Metabolic Care 2014; 17:

29 Probiotic and synbiotics Bifidobacterium longum plus fructo-oligosaccharides (FOS) versus placebo Results at day 90 NH4 levels MMSE Synbiotic Placebo 22 Synbiotic Placebo Before After Before After M. Krystel Malaguarnera,et Ouaijan - Dubai al. Digestive Diseases and Sciences 2007, 52 (11),:

30 Probiotic and synbiotic The treatment with Bifidobacterium + FOS is an alternative to the use of lactulose in patients with cirrhosis, for its usefulness in reducing blood ammonia levels and improvement of psychometric tests. New trial has shown similar effects with a probiotic yoghurt. Bajaj et al. American Journal of Gastroenterology 2008, 103 (7):

31 Take home messages Assess for malnutrition using bedside methods with your own clinical judgment Protein: g/kg/day with focus on vegetable protein BCAA in overt hepatic encephalopathy If protein restriction is to be done, it should be limited to a very restricted day Use prebiotics and probiotics in addition to the conventional treatment

32 Final Thought! To improve is to change; to be perfect is to change often.

33 References Mouzaki et al. Enteral energy and macronutrients in end-stage liver disease. Journal of Parenteral and Enteral Nutrition 2014; 38 (6) Nutritional status in cirrhosis. Italian Multicentre Cooperative Project on Nutrition in Liver Cirrhosis. Journal of Hepatology 1994; 21: Bemeur et al. Role of nutrition in the management of hepatic encephalopathy in end-stage liver failure. Journal of Nutrition and Metabolism 2010; Alberino et al. Nutrition and survival in patient with cirrhosis. Nutrition 2001; 17: Campillo et al. Validation of body mass index for the diagnosis of malnutrition in patients with liver cirrhosis. Gastroenterology Clinical Biology 2006; 30: Bajaj et al. Probiotic yogurt for the treatment of minimal hepatic encephalopathy. American Journal of Gastroenterology 2008, 103 (7):

34 References Morgan et al. Derivation and validation of a new global method for assessing nutritional status in patients with cirrhosis. Hepatology 2006; 44: Alvares et al. Comparison between handgrip strength, subjective global assessment, and prognostic nutritional index in assessing malnutrition and predicting clinical outcome in cirrhotic outpatients. Nutrition 2005;21 (2): Plauth et al. ESPEN guidelines on enteral nutrition: liver disease. Clinical Nutrition 2006; 25: Mullen et al. Protein restriction in hepatic encephalopathy: necessary evil or illogical dogma. Journal of Hepatology 2004; 41 (1): Cordoba et al. Normal protein diet for episodic hepatic encephalopathy: results of a randomized study. Journal of Hepatology 2004; 41 (1): M. Malaguarnera,et al. Bifidobacterium longum with fructo-oligosaccharide (FOS) treatment in minimal hepatic encephalopathy: a randomized, double- blind, placebo-controlled study. Digestive Diseases and Sciences 2007, 52 (11),:

35 References Gheorghe et al. Improvement of hepatic encephalopathy using a high protein high calorie modified diet. Romanian Journal of Gastroenterology 2005; 14 (3): Johnson et al. Nutrition assessment and management in advanced liver disease. Nutrition in Clinical Practice 2013; 28 (1): Gluud et al. Branched-chain amino acids for people with hepatic encephalopathy. The Cochrane Database of Systematic Reviews 2015; 9: Fukushima et al., Nocturnal branched- chain amino acid administration improves protein metabolism in patients with liver cirrhosis: comparison with daytime administration. Journal of Parenteral and Enteral Nutrition 2003; 27 (5): Amodio et al. Dietary management of hepatic encephalopathy revisited. Current Opinion in Clinical Nutrition and Metabolic Care 2014; 17: M. Malaguarnera et al., Bifidobacterium combined with fructo-oligosaccharide versus lactulose in the treatment of patients with hepatic encephalopathy European Journal of Gastroenterology and Hepatology 2010,