Nutrition In Disease Management

Transcription

1 Centre For Research On Nutrition Support Systems Nutrition In Disease Management UPDATE SERIES 53 JANUARY 2012 Role of Nutrition In The Management of Liver Transplantation For End Stage Liver Disease Nutritional Management For Pre And Post Liver Transplant A Case Report Nutritional Management of A Child With Tufting Enteropathy : A Case Report Nutrition Foundation of India Building, C-13 Qutab Institutional Area, New-Delhi Tel: , Fax: nfi@nutritionfoundationofindia.res.in; crnssindia@gmail.com Website:

2 To Our Readers Role of Nutrition In The Management of Liver Transplantation For End Stage Liver Disease Ms. Daphnee.D.K, Senior Dietitian, Apollo Hospitals, Chennai Dr. Anand Khakhar, Consultant Hepatobiliary & Transplant Surgeon, Apollo Hospitals, Chennai Dr. Bhuvaneswari Shankar, Group Chief Dietitian, Apollo Hospitals Group. Dear Readers, The current issue (52) of the CRNSS Update Series Nutrition in Disease Management consists of a lead article about a widely discussed subject in the field of nutrition, trans fatty acids. The article describes details of research on trans fatty acids carrier out both nationally and internationally and also discusses the relevance of trans fatty acids in specific clinical situations. The lead article is followed by a very brief description of a practical approach to dietary management in a patient with methylmalonic acidemia, a disorder of amino acid metabolism, which is a nutritional challenge. Dr. Sarath Gopalan Executive Director, CRNSS and Editor Introduction Nutrition is an integral part of health maintenance. The liver is the largest and most important metabolic organ, playing a pivotal role in integrating several biochemical pathways of carbohydrate, fat, protein, and vitamin metabolism. Malnutrition is a common complication of end-stage liver disease (ESLD). Progressive deterioration of nutritional status has been associated with poor outcome in cirrhotic patients.(1) Liver transplantation (LT) revolutionized the management of liver disease.(2) This article focuses on nutritional problems seen in patients with ESLD, with particular emphasis on nutritional assessment and support of patients before and after liver transplantation. Malnutrition Protein-energy malnutrition (PEM) is common in patients with ESLD and is highly prevalent in all Forms of liver disease, regardless of etiology.(3) Accurate estimation of the nutritional status in patients with ESLD represents a major challenge due to fluid retention found in a significant number of patients and the effect of liver function on protein synthesis.(1) Protein deficiency can be found in early stages of cirrhosis.(4) PEM tends to be more frequent in advanced cirrhosis. The diagnosis of PEM in ESLD may not be that difficult to make because of marked muscle wasting and subcutaneous fat loss. The prevalence of PEM has been reported to be as high as 100% in patients undergoing LT.(1,5) Despite these challenges, PEM can be diagnosed in 20% of patients with compensated liver disease and in greater than 80% of patients with decompensated liver disease - in other words, those with ascites, portosystemic hepatic encephalopathy, and portal hypertensive bleeding. PEM is more prevalent in patients hospitalized for alcoholic liver disease than in patients with nonalcoholic liver disease.(6) PEM has been associated with adverse outcomes, including decreased patient and graft survival after LT.(5) Etiology of malnutrition in chronic liver disease Edited by: Sarath Gopalan, Executive Director, CRNSS Nutrition in Disease Management Published jointly by CRNSS and Nutrition Foundation of India, Designed and produced by Natural Impression Malnutrition in patients with ESLD is multifactorial (Table 1) However, major determinants are abnormal nutrient and caloric intake, decreased intestinal absorption, and metabolic disturbances. (7) 1

3 Table 1. Etiology of Malnutrition in ESLD Poor dietary intake Anorexia and early satiety Dietary restriction (sodium and protein) Ascites/encephalopathy Leptin levels Increased proinflammatory cytokines (interleukin 1) Gastroparesis, nausea and vomiting Nutrient malabsorption Pancreatic insufficiency Cholestatic liver disease Drug-induced losses Neomycin, lactulose, diuretics, antimetabolites, cholestyramine Iatrogenic Large-volume paracentesis Altered fuel metabolism Patients with hepatic failure have accelerated starvation, with an early recruitment of alternative fuel sources. Cirrhotic patients demonstrate significantly increased fat oxidation and gluconeogenesis with protein catabolism after an overnight fast. It would take a healthy adult approximately 72 hours of starvation to reach the same level of fat oxidation and protein catabolism as occurs in an overnight fast in a cirrhotic patient (8, 9). It is believed that the diminished hepatic and muscle glycogen stores that occur with cirrhosis is a factor in this accelerated rate of starvation. Patients without adequate glycogen stores utilize increased fat and muscle protein for fuel even during short-term fasting. This contributes to the loss of subcutaneous fat and muscle wasting that is the hallmark of malnutrition. Insulin resistance and decreased levels of insulin like growth factor-1 are also believed to contribute to muscle wasting in cirrhosis. (10) Nutrition Assessment To determine the presence of malnutrition in a liver transplant candidate, a thorough nutritional assessment must be performed. A subjective global assessment method for liver transplant. Anthropometrics (as appropriate and age dependent) Ideal body weight (IBW) Weight Height Mid arm circumference (MAC) Triceps skin fold Mid arm muscle circumference (MAMC) Weight history Presence of Ascites Laboratory values Laboratory tests may reflect liver dysfunction and / or portal hypertension. Albumin / Prealbumin Lymphocyte counts Nutrition intervention is advocated according to the assessment and supplements to oral nutrition or enteral feeding are recommended. For ESLD patients, highly individualized, aggressive nutrition support is usually necessary to minimize catabolism and slow the deterioration of nutritional status while awaiting a donor organ, preferably with the guidance of an experienced dietitian. Goals of Nutritional therapy in ESLD patients waiting for Liver transplant Correct malnutrition and prevent metabolic complications Educate patients and caregivers on individual plan for nutrition and level of activity. Improve quality of life. 2 3

4 Reduce preoperative 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 protein is limited only in patients with severe hepatic encephalopathy to g / 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. H o w e v e r, s a l t r e s t r i c t i o n s i g n i f i c a n t l y d e c r e a s e s t h e 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 u s e f u l 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. A bedtime snack is critical to help reduce the breakdown of lean muscle mass during the overnight fast (8). Immediate postoperative state 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 2. Table 2. Nutrition recommendations after liver transplant NUTRIENTS SHORT TERM LONG TERM Calories % of BEE Maintenance: % 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% of total calories Calcium 1200mg / day 1500mg / day Vitamins & Minerals According to RDA levels According to RDA levels Estimated energy requirements in the immediate post operative s t a g e 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 postoperative complications Nasoenteric tube feeding is recommended as soon as the patient is hemodynamically stable. TPN is considered only w h e n enteral route cannot be used. 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. 4 5

5 Small, frequent feeds, including high energy, 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: 1g/kg/day. Discharge Diet and Education Low salt Highly salted foods like pickles, pappad, salt snacks and savories and any food preserved in salt are avoided. Oral supplement According to the individual requirement, high energy, protein supplements to be suggested till oral intake is adequate. Educate the patient and family on post organ transplant food hygiene measures and guidelines. Conclusion Nutritional aspects are important both for patients awaiting liver transplantation and for those who live on with a liver graft.while pre-transplant patients and those in the immediate post-transplant period usually require correction of numerous nutritional deficiencies to improve transplant programs. References 1. Lochs H, Plauth M. Liver cirrhosis: rationale and modalities for nutritional support the European Society of Parenteral and Enteral Nutrition consensus and beyond. Curr Opin Clin Nutr Metab Care 1999;2: Review. 2. Tran TT, Nissen N, Poordad FF, Martin P. Advances in liver transplantation. New strategies and current care expand access, enhance survival. Postgrad Med 2004;115:73-76, Review. 3. McCullough AJ, Bugianesi E. Protein calorie malnutrition and the etiology of cirrhosis. Am J Gastroenterol 1997;92: Prijatmoko D, Strauss BJ, Lambert JR, Sievert W, Stroud DB, Wahlqvist ML, et al. Early detection of protein depletion in alcoholic cirrhosis: role of body composition analysis.gastroenterology 1993;105: Hasse JM. Nutritional implications of liver transplantation.henry Ford Hosp Med J 1990;38: Marsano L. Nutrition and alcoholic liver disease. JPEN J Parenter Enteral Nutr 1991;15: Antonio J. Sanchez and Jaime Aranda-Michel. Nutrition for the Liver Transplant Patient, Liver Transplantation12: , 2006, 2006 American Association for the Study of Liver Diseases. 8. Wei-Kuo C, You-Chen C, Hung-Shang T, Hui-Fen L, Chung-Te H.Effects of extra-carbohydrate supplementation in the late evening on energy expenditure and substrate oxidation in patients with liver cirrhosis. JPEN, 1997; 21: Crawford D. Recent advances in malnutrition and liver disease.what s New in Gastroenterology, 1995;48:1-4. Nutritional Management Of A Child With tufting Enteropathy : A Case Report 10. Joseph Krenitsky MS, RD, Nutrition for Patients with Hepatic Failure, Practical Gastroenterology, June, 2003;6: their overall condition, post-transplant liver patients have to be followed up to ensure they do not develop over nutrition. Both settings require an interdisciplinary approach that integrates the expertise of physicians, surgeons, nutritionists, and nursing staff who are well-aware of these issues. It is only with a multidisciplinary team effort that nutritional imbalances can be overcome to optimize the outcome in patients in liver 6 7

6 Nutritional Management For Pre And Post Liver Transplant A Case Report Ms. Daphnee.D.K, Senior Dietitian, Apollo Hospitals, Chennai Dr. Anand Khakhar, Consultant Hepatobiliary & Transplant Surgeon, Apollo Hospitals, Chennai Dr. Bhuvaneswari Shankar, Group Chief Dietitian, Apollo Hospitals Group. PRE OPERATIVE A 51yrs old Japanese male was admitted with decompensated chronic liver disease, diarrhea, altered sensorium, and abdominal distension. Nutritional management during pre and post operative stay in the hospital is discussed in this case study. Nutrition screening on admission Nutrition screening was performed routinely by the doctor and referred to the dietitian for further assessment Nutrition Assessment The dietitian completed the nutrition assessment using Subjective Global Assessment (SGA) and Anthropometry: Height: 184cms; Weight: 60.4kg; BMI: 19; In the previous 6 months, he had a weight loss of 9%, and assessment of oral intake showed moderate overall decrease due to ascites, diarrhoea, abdominal pain etc., He had difficulty in carrying out normal daily activity. The SGA revealed moderate malnutrition. On admission, he was prescribed salt-free (SF), 1000ml fluid-restricted (F/R), Semi Solid Diet with nocturnal Ryle s tube feeds 50ml/hr (9pm 7am). Since his oral intake was poor on day 3, continuous RTF was initiated and the diet changed to SF, 1000ml F/R, RTF@ 40ml/hr with Semi Solid Diet. On day 10, as oral intake improved, diet changed to 5g salt-restricted diet (S/R), 650ml F/R diet with Nocturnal RTF@ 60ml/hr (9pm 7am). Due to abdominal pain he was not able to eat, so on day 13, continuous RTF was initiated and the diet changed to 5g S/R, 1250ml F/R, RTF@ 50ml/hr with Diet. Diet was changed on day 20 as his oral intake improved to 4g S/R, 550ml F/R Diet with 70ml/hr Nocturnal RTF (9pm 7am). Nutrition Education Educated the patient about the salt and fluid restrictions and emphasized on increased energy and protein intake and importance of enteral tube feeding. Nutrition monitoring Daily intake was monitored by the dietitian using a food and fluid chart and energy intake was documented. The nutritional requirements were met by oral and enteral (tube) feeding. The daily energy and protein intake is given in the fig.1 and fig.2 respectively. The lab values like Hb, Serum Albumin, Lymphocytes, Na, and K etc. were reviewed daily. Fig.1 Daily energy intake Nutrition Care Plan The energy requirement was 2309, calculated using Harris Benedict equation and the protein requirement was derived using predisposition weight = 90. The prescription for salt and fluids is as follows: Salt g / day Fluid litres / day 8 9

7 Fig.2 Daily protein intake Post Operative The patient was readmitted after a week for cadaveric liver transplant. Nutrition screening on admission Nutrition screening was routinely performed by the doctor and referred to the Dietitian for further assessment Nutrition Assessment The nutrition assessment was performed by the dietitian using SGA which revealed moderate malnutrition inspite of slightly improved oral intake along with enteral tube feeding. Nutrition Care Plan Nutrition therapy evaluation The reasons for modification in nutritional management are as follows: Intolerance Salt & fluid restriction Abdominal Pain Hepatic encephalopathy Nausea The post OP energy requirement is same as pre OP requirement calories and the Protein was calculated as predisposition weight = 98g. To meet the increased demand normal oral sip feed supplement was suggested from day 2. Immediate Post - operative Diet Day 1 - Clear liquids from 6pm Day 2 - Soft Solid diet from afternoon Day 3 - Normal diet Day 6 - Low Potassium diet Day 10 - Normal diet Discharge Education He was discharged on the following diet prescription - 4g Salt, 650ml F/R, diet with nocturnal 60ml/hr for 10hrs.The dietitian educated the patient & family about the diet to be followed at home and explained in detail about enteral tube preparation and feeding techniques. A diet chart was provided. Nutrition education and monitoring He was educated on the phases of diet and the Dietitian monitored the daily intake by using a food and fluid chart and energy intake was documented. The nutritional requirements were met by oral diet and oral sip feed supplements. The daily energy and protein intake is given in the fig.5 and fig.6 respectively. The lab values like Hb, Serum Albumin, Lymphocytes, Na, and K etc. were reviewed daily

8 Fig.5 Post OP daily energy intake Nutrition therapy evaluation The reasons for deviations in providing the required nutrition are as follows: Post OP stress Pain Cultural differences Discharge Diet Education Discharge diet prescription: Normal diet Educated the patient & family on the post operative higher requirement of energy and protein, post transplant food hygiene protocol and suggested to continue oral sip feed supplement till oral intake was adequate and diet chart was provided. Note: Patient was educated with the help of a translator throughout his stay. Fig.5 Post OP daily protein intake 12 13

9 Nutritional Management of a Child With Tufting Enteropathy : a Case Report Lekha V.S, Senior Dietitian, ACH Dr. Srinivas S, Pediatric Gastroenterologist Dr. Bhuveneshwari Shankar, Group Chief Dietitian, Apollo Hospitals 2 month old male child born to a non consangious parents, was brought to Apollo Children s Hospital on for an evaluation of probable congenital secretory diarrhea. The weight on admission was 2.4 kg. He underwent repeat GI scopy and duodenal biopsies were sent for analysis, which confirmed the rare diagnosis of TUFTING ENTEROPATHY. He was started on Enteral Nutrition (elemental amino acid based tube feed formula ( 15 ml/hr providing Calorie 240 k.cal, Protein 7.4 gms) for 10 days as a continuous nasogastric infusion but did not gain any weight and no improvement in weight suggesting significant malabsorption and need for TPN. Along with EN he was started on TPN. Pre Operative Nutrition Intervention Date Route Product Vol Rate CHO PRT(gm) Fat(gm) Total K.Cal (ml) (gm) Peripheral PN pdt with 192 8ml/hr MCT & LCT EN Peptide formula ml/hr Central PN pdt with 144 6ml/hr MCT & LCT + Initiated oral feeds Peptide formula -Trophic feeds Peripheral 14% DNS ml/hr %Aminoven ml/hr for 12 hr 10 20% Lipidem 36 ml 3 ml/hr 7.2 gm 322 for 12 hr During the course of his hospital stay, he had profuse watery diarrhea with dehydration and recurrent dyselectrolytemia needing continuous intravenous fluid replacement up to 300ml/kg/day. Despite TPN he failed to gain weight. Further, he also developed severe necrotizing enterocolitis during 4th week of admission and underwent resection of the bowel from proximal jejunum to sigmoid colon. In the post-operative period, total parenteral nutrition (TPN) was initiated on 3rd Pod. TPN formulation included calculation of Carbohydrate, Protein,Fat, Vitamins,Minerals and Trace elements. The objective was to provide 60% of the calorie from carbohydrate, 20% from protein, 20% from fat. Electrolytes were added to available maintenance fluid. Liver protective strategies that is followed 1. Do not exceed lipid > 3 g /Kg/ day 2. After establishing reasonable weight gain, give 2 day off on lipid. 3. Gradually give 2-3 hour off TPN completely. 4. Continue trophic feeds. 5. Periodic monitoring of liver function test. Post Operative Nutrition intervention Route CENTRAL LINE Date Product Volume Rate Hrs CHO PRT FAT Total (gm) (gm) (gm) K.cal 3, pod PN Pdt with MCT & LCT + 216ml 9ml/hr 24 hrs % DNS 360ml 15ml/hr 7, pod PN Pdt with MCT&LCT + 216ml 9ml/hr 24 hrs % DNS 432ml 18ml/hr 10, pod PN Pdt with MCT&LCT + 240ml 10ml/hr 24 hrs % DNS 432ml 18ml/hr 16, pod PN Pdt with MCT&LCT+ 264ml 11ml/hr 24 hrs % DNS 432ml 18ml/hr 21, pod PN Pdt with MCT&LCT+ 270ml 18ml/hr 15 hrs % DNS 432ml 18ml/hr 24 hrs 24, pod PN Pdt with MCT&LCT+ 270ml 15ml/hr 18hrs % DNS 480ml 20ml/hr 24hrs 35, pod Started off lipids for 2 days in a week PN Pdt with out MCT & LCT+ 270ml 15ml/hr 18hrs % DNS 480ml 20ml/hr 24hrs 41, pod PN Pdt with MCT&LCT+ 270ml 15ml/hr 18hrs % DNS 506ml 23ml/hr 22hrs 48, pod PN Pdt with MCT&LCT+ 306ml 17ml/hr 18hrs % DNS 506ml 23ml/hr 22 hrs 52, pod PN Pdt with MCT&LCT+ 306ml 17ml/hr 18hrs %DNS 550ml 25m/hr 22hrs 70, pod PN Pdt with MCT&LCT+ 306ml 17ml/hr 18hrs %DNS 567ml 27ml/hr 21hrs 90, pod PN Pdt with MCT&LCT 306ml 17ml/hr 18hrs %DNS 462ml 22ml/hr 21hrs 14 15

10 As he was only 6 month old, he was started on weaning foods in a semisolid consistency along with parenteral nutrition (PN). It is important to monitor serum electrolytes, liver function test & lipid profile. Initially bi-weekly and subsequently once a week during long term TPN treatment. Blood glucose was monitored daily till it stabilized, then stopped. It is only after enterectomy that he started gaining weight on TPN. From only 2.4 Kg prior to surgery, he has now gained 2 Kg over a period of 3 month weighing now 4.5 Kg, still on TPN and is awaiting small bowel transplant.this case is presented for its rarity and complex management issues. Successful nutritional management in such a TPN - dependent condition is possible, but needs a dedicated and skilled team of Doctors, Dietitian and Nurses. Governing Body of CRNSS Dr. S. Padmavati Director, National Heart Institute, New Delhi Dr. C. Gopalan President, Nutrition Foundation of India, New Delhi Dr. Prema Ramachandran Director, Nutrition Foundation of India, New Delhi Dr. Kamala Krishnaswamy Senior Emeritus Scientist, National Institute of Nutrition, Hyderabad President Member Member Member Dr. S. Ramji Professor, Department of Pediatrics, Maulana Azad Medical College, New Delhi Member Ms. Malini Seshadri Freelance Writer and Company Secretary, Chennai Treasurer Mr. Rakesh Bhargava Managing Director & CEO, Fresenius Kabi India Limited Member Dr. Sarath Gopalan Consultant, Clinical Nutrition and Pediatric Gastroenterologist Pushpawati Singhania Research Institute, New Delhi Executive Director CRNSS is a Registered Society under the Societies Registration Act of This Update Series is published jointly by CRNSS and NFI four times a year. The latest information and advances in the area of nutrition, special systems in the management of diseases are presented for the benefit of medical practitioners and dieticians. 16