The Liver. Joy Phillips, Jen Brereton, DJ Johnson, Marquie Miller

Transcription

1 The Liver Joy Phillips, Jen Brereton, DJ Johnson, Marquie Miller

2 The Liver Only 10-20% of the liver is needed to survive Approximately 2% of an adult s body weight Removal of liver causes death within 24

3 The Liver Functions o Carbohydrate metabolism o Transamination, oxidative deamination, protein synthesis o Blood-clotting factors (fibrinogen, prothrombin, etc.) o Beta-oxidation, fatty acid metabolism o Storage, activation, transport of vitamins & minerals o Bile formation and excretion o Converts ammonia to urea for kidneys to excrete o Metabolizes steroids (aldosterone, glucocorticoids, estrogen, etc.) o Detoxifies body of drugs and alcohol o Filters by removing bacteria and debris through phagocytic Kupffer cells

4 Storage of Vitamins and Minerals Hepatocytes store excess nutrients and vitamins and releases them when needed. Vitamins cannot be stored as well if the liver is damaged, therefore causing vitamin deficiencies in those with liver disease.

5 Bile Formation and Excretion The liver forms and excretes bile Bilirubin (from erythrocytes) is conjugated and excreted in the bile If liver isn t functioning properly, it can t eliminate enough bilirubin, causing jaundice.

6 Ammonia to Urea Hepatocytes detoxify ammonia by converting it to urea, which is excreted by the kidneys. Ammonia is a direct cerebral toxin High ammonia levels lead to impaired neural function

7 Diseases of the Liver 1. Acute Viral Hepatitis 2. Fulminant Hepatitis 3. Chronic Hepatitis 4. Nonalcoholic Fatty Liver Disease (NAFLD) 5. Nonalcoholic Steatohepatitis (NASH) 6. Alcoholic Hepatitis and Cirrhosis 7. Cholestatic Liver Diseases 8. Inherited Disorders 9. Other Liver Diseases

8 NAFLD Nonalcoholic Fatty Liver Disease Accumulation of fat within the liver d/t FA metabolism from adipose tissue or increase TG synthesis Can lead to NASH (Nonalcoholic Steatohepatitis)

9 Causes & Risk Factors of NAFLD Causes Drugs Inborn/acquired metabolic disorders DM II Lipodystrophy Jejunal ileal bypass OB Malnutrition Risk Factors OB DM Dyslipidemia IR

10 NASH Nonalcoholic Steatohepatitis Accumulation of fibrous tissue in liver Theory: IR leads to oxidative stress

11 S/S and Tx of NASH S/S Malaise Weakness Hepatomegaly Tx Gradual wt loss Insulin-sensitizing drugs Treat dyslipidemia Fat wt loss can lead to cirrhosis and gallstones

12 Cirrhosis Combination of chronic liver diseases causing scar tissue to replace normal liver cells which hinders blood flow decreasing the function of the liver leading to liver failure

13 Healthy Liver Fibrosis Fatty Liver Alcoholic Hepatitis Necrotic Liver CIRRHOSIS

14 Causes of Cirrhosis Alcohol (risk directly related to intake) + poor diet Hepatitis B and C Hemochromatosis: accumulation of Fe in liver due to increase absorption Wilson s disease: accumulation of copper in liver due to genetic disease

15 The 3 Stages of Alcoholic Liver Disease Hepatic Steatosis Alcoholic Hepatitis Alcoholic Cirrhosis

16 Complications of Alcohol Intake Excessive alcohol consumption causes excess hydrogen and acetaldehyde to form

17 Hepatic Steatosis Fatty liver Caused by in mobilization of FA from adipose tissue in hepatic synthesis of FAs in FA oxidation in triglyceride production Trapping of triglycerides in the liver Reversible with abstinence from alcohol

18 Alcoholic Hepatitis Characterized by Hepatomegaly Increase bilirubin concentrations Anemia Abdominal pain Anorexia weight loss N/V Weakness Diarrhea Fever Condition can resolve if alcohol discontinued

19 Alcoholic Cirrhosis S/S can mimic those of alcoholic hepatitis Additional S/S GI bleeding Hepatic encephalopathy Portal hypertension Ascites Jaundice

20 How do you know if you have liver disease? How do you know if you have liver disease?

21 Hepatic Encephalopathy (PSE) Increased BP in portal venous system caused by decreased blood flow through liver Leads to decreased brain function d/t inability of liver to filter toxins from blood S/S: o o Dx: o o o Mental abnormalities Brain swelling Scans Blood work Glascow coma score

22 Four Stages of Hepatic Encephalopathy 1. Mild confusion, agitation,irritability, sleep disturbance, decreased retention. 2. Lethargy, disorientation, inappropriate behavior, drowsiness. 3. Somnolent but arousable, incomprehensible speech, confused, aggressive behavior when awake. 4. Coma

23 GLASGOW COMA SCORE Neurological scale to assess level of consciousness Test responses: verbal eye motor Interpretations <8 severe brain injury >13 minor brain injury

24 Ascites Retention of fluid, proteins, and electrolytes in peritoneal cavity d/t increased portal HTN and decreased albumin synthesis

25 COMORBIDITIES Caput medusae Esophageal varices Telangiectasis Gynecomastia

26 Esophageal Varices Esophageal Varices

27 Dx of Cirrhosis Hx: lifestyle, behavioral changes Liver biopsy Blood tests

28 Labs for Cirrhosis Serum bilirubin Alkaline phosphatase Aspartate aminotransferase Alanine aminotransferase Serum ammonia Gamma-glutamyl transferase Albumin Prothrombin time

29 Serum Bilirubin Used to evaluate liver function Elevated levels of unconjugated Normal >15 mg/dl

30 Alkaline Phosphatase (ALP) Used to detect and monitor liver disease Highest concentration in liver biliary duct Excreted into the bile Increased with obstruction of bile duct and liver dysfunction Normal: units/l

31 Aspartate Aminotransferase (AST) Used to evaluate suspected hepatocellular diseases Cells lyse d/t disease or injury of cell; enter blood stream to increase serum levels AST elevation directly related to # of cells affected Elevated in 8 hours, peak hours, cleared from blood in a few days unit/l

32 Alanine Aminotransferase (ALT) Identifies hepatocellular diseases Monitor improvement/worsening of hepatic diseases Elevation caused by liver dysfunction Can be elevated by many drugs AST/ALT ratio Normal: 4-36 units/l

33 AST: ALT Ratio Used to dx liver disease Normal: ALT>AST <1 in liver disease but >1 in viral hepatitis

34 Gamma-Glutamyl Transferase (GGT) Indicator of liver disease as well as heavy and chronic alcohol use GGT helps with transfer of AA and peptides Highest concentrations in liver and biliary tract Elevated in liver disease Normal: 5-38 units/l

35 Serum Ammonia Used to support dx, monitoring and follow-up of liver disease and hepatic encephalopathy Increased d/t portal HTN Normal mcg/dl

36 Albumin Used to dx, evaluate, and monitor diseases Formed in liver, synthesis decreases with liver dysfunction Maintain osmotic pressure, transporter protein Normal: g/dl

37 Prothrombin Time (PT) Used to evaluate clotting ability Increased PT with liver disease d/t decreased synthesis of many clotting factors Normal: seconds INR:

38 Other Labs 1. Na: 2. K: 3. Ca: 4. Ph: 5. Hgb: 6. Htc: 7. Cl: 8. CO2: 9. Glu: 10.BUN: 11. Creat:

39 Medical Treatment

40 Medical Treatment Lasix/Furosemide Spinonolactone Lactulose Rifaxmin/neomysin Transplant

41 Diuretics Help rid the body of salt and water Make kidneys put more sodium into urine Sodium pulls water from the blood into the urine Used to treat edema and ascites

42 Diuretics Lasix/Furosemide Loop diuretic Help treat fluid retention and swelling Acts on kidneys to increase urine flow Spironolactone Diuretic increases urinary sodium excretion Potassium sparing

43 Decrease Ammonia Lactulose Acidifies colon content Retaining ammonia as ammonium ions Acts as osmotic laxative to remove the ammonia Rifaximin and neomysin Antiboitics Decrease colon production of ammonia Stop growth of bacteria that produces toxins

44 Transplant Recommended for people who have end-stage liver disease (ESLD) A surgical procedure performed to replace disease liver with a healthy one Donor may be living or dead

45 Transplant Evaluation Process Psych and social evaluation Stress, financial, family support Blood Tests Donor match, priority on list, improve chances of organ acceptance Diagnostic Tests Overall health status,

46 Liver Transplant Currently 16,000 Americans on the waiting list for a liver 6000 undergo liver transplant annually About 2000 die every year waiting for a liver

47 Survival Rate 87% at 1 year 73% at 5 years 59% at 10 years Most patients my resume regular lifestyle at six months to a year

48 Liver Transplant Surgery complications include: Bleeding Infection Blockages of blood vessels Leakage of bile Initial lack of function of new liver Must take antirejection meds after surgery

49 Liver Transplant Living vs. Cadaver Living: remove from donor and both donor and recipient liver will grow to normal size Cadaver: donor is typically a victim of an accident. Family must agree to withdraw life support. It is considered an anonymous gift

50 Alternative Therapy Milk Thistle Silibinin is the active ingredient Increases antioxidant concentrations and improves the outcomes in hepatic diseases Associated with protection against hepatic toxins Decrease in hepatic inflammation and fibrosis

51 Cochrane Systematic review could not demonstrate significant effects of milk thistle on mortality or complications

52 Regeneration Within a week of partial hepatectomy hepatic mass is essential back to what it was prior to surgery two- Typically surgically remove thirds of the liver

53 Regeneration Hepatectomy leads to proliferation of all populations of cells within the liver DNA synthesis is initiated in these cells within hours after surgery Hepatocytes have practically unlimited capacity for proliferation Full regeneration observed after as many as 12 sequential partial hepatectomies

54 Medical Nutrition Therapy

55 Nutrition Assessment Traditional markers of nutrition status are affected by liver disease Use a combination of anthropometric measurements, dietary intake, and SGA Moderate to severe malnutrition is common in patients with liver disease

56 Subjective Global Assessment (SGA) Body weight is affected by edema, ascites, and diuretic use Visceral protein levels are affected by hydration status, malabsorption, and renal insufficiency Box 30-1 History Physical Findings Existing Conditions Nutritional Rating Based on Results

57 SGA-History Weight change Appetite consider fluctuations resulting from ascites and edema Taste changes and early satiety Dietary intake calories, protein, sodium Persistent GI problems

58 SGA-Physical Findings Muscle Wasting Fat stores Ascites or edema

59 SGA-Existing Conditions Disease state and other problems that could influence nutritional status Hepatic encephalopathy GI bleeding-varices Renal Insufficiency Infection

60 SGA-Nutritional Rating Based on Results Well nourished Moderately malnourished Severely malnourished

61 Nutrient Requirements-Energy REE varies among patients Hypo, Hyper, or normal In general, requirements of ESLD patients with ascites increase 120% to 175%; w/o ascites 150%-175% Equates to 25-35kcal/kg Use dry body weight in calculations

62 Nutrient Requirements-Carb Liver failure reduces glucose production and glycogen storage Lipids and AA are used as energy Alterations in hormones specifically insulin, glucagon, cortisol and epinephrine Presence of insulin resistance

63 Nutrient Requirements-Lipids Preferred source of energy Increased lipolysis Lipid storage is not impaired 25-40% kcal

64 Nutrient Requirements-Protein Nitrogen losses only in fulminant hepatic failure NOT in stable cirrhosis Cirrhosis w/o encephalopathy: g/kg dry body weight Positive nitrogen balance: g/kg dry body weight Alcoholic hepatitis, sepsis, infection, GI bleeding, or severe ascites: at least 1.5 g/kg

65 Nutrient Requirements-Vitamins Supplementation is needed for all ESLD patients Deficiencies can lead to further complications (Table 30-5) Copper and Manganese should not be supplemented Zinc, Magnesium and Calcium should be at least DRI levels

66 Herbal Supplements Bad: Terpenoid containing supplements Germander, Sho-saiko-to, Centella asiatica, black cohosh, etc. Good: Milk thistle and S-adenosyl-Lmethionine

67 Nutrition Management Increased energy via small frequent meals Sodium restriction for fluid retention (2 g/day) Fluid restriction for hyponatremia (1-1.5 L/day) CHO-controlled diets for hyperglycemia Vitamin and mineral supplements Oral liquid supplements or enteral feeding

68 NutriHep Appropriate for: lactose intolerance*, gluten-free, low-residue, kosher * Not for individuals with galactosemia kcal/ml: 1.5 Caloric Distribution (% of kcal) Protein: 11% Carbohydrate: 77% Fat: 12% Protein Source: crystalline L-amino acids, whey protein concentrate NPC:N Ratio: 209:1 MCT:LCT Ratio: 70:30 n6:n3 Ratio: 4:1 Osmolality (mosm/kg water): 790 Water: 76% Meets 100% RDI for 19 key micronutrients: 1000 ml HCPCS Code B4154 High ratio of branched-chain amino acids to aromatic amino acids Calorically dense for fluid management High MCT to LCT ratio to facilitate absorption May be used for tube feeding or for oral supplementation

69 MNT-Fat Malabsorption Caused by decreased bile salt secretion, administration of neomycin or cholestyramine, and pancreatic enzyme insufficiency Replace long-chain tryglycerides with medium-chain trglycerides

70 MNT-Osteopenia Weight maintenance 1500 mg/day of calcium Adequate vitamin D Avoidance of alcohol Monitor for steatorrhea Adequate protein to maintain muscle mass

71 MNT-NAFLD and NASH Gradual weight loss if overweight Losing weight too fast accelerated development of cirrhosis and increases risk of gallstones Eat a heart healthy diet Fruits, Vegetables, whole grains: Low in saturated fat and cholesterol Control blood sugar Exercise and be physically active

72 MNT-Hepatic Encephalopathy Liver is unable to detoxify ammonia Ammonia levels are elevated in the brain and bloodstream Main source of ammonia is from the metabolism of exogenous protein NOT PROVEN CORRECT

73 MNT-Hepatic Encephalopathy Branched-chain amino acids (BCAAs) (valine, leucine, and isoleucine) are decreased Aromatic amino acids (AAAs) (tryptophan, phenylalanine, and tyrosine) are increased High levels of AAAs may limit the cerebral uptake of BCAAs because they compete for carrier-mediated transport at the brain-blood barrier No significant imporvements or survival benefits associated with giving extra BCAAs to patients

74 MNT-Hepatic Encephalopathy Tolerate mixed-protein diets up to 1.5g/kg of dry body weight Casein and vegetable proteins may improve mental status compared with meat protein Probiotics and synbiotics may be beneficial Reduce inflammation and oxidative stress

75 MNT-Liver Transplants Protein and energy needs increase Patients should eat small, frequent, nutrient dense meals Because PN can adversely affect liver function, EN is preferred PN is reserved for patients with poor gut function Dietary modification is based on specific side effects of drug therapy

76 MNT-Liver Transplants Pretransplantation Immediate Post Long term Post Calories and protein High calorie & Moderate protein Moderate calorie & High protein Weight maintenance & moderate protein Fat As needed 30% of calories Moderate fat Carbohydrate Reduced simple CHO Reduced simple CHO Reduced simple CHO Sodium 2g/day 2-4g/day 2-4g/day Fluid Restrict to mL/day As needed As needed Calcium mg/day mg/day mg/day Vitamins Multivitamin supplementation to DRI levels; additional water and fat soluble vitamins as indicated Multivitamin supplementation to DRI levels; additional water and fat soluble vitamins as indicated Multivitamin supplementation to DRI levels

77 Case Study: Teresa Wilcox 26 y.o. Doctoral student Diagnosed 3 years ago with hepatitis C

78 Anthropometrics 26 y.o. BMI 19 86% of IBW, 7% weight loss in the past 6 months

79 Biochemical Bilirubin 3.7mg/dL (high) Protein 5.4g/dL (low) Albumin 2.1g/dL (low) Prealbumin 15mg/dL (low) Alkaline phosphatase 275U/L (high) ALT 62U/L (high) AST 230 U/L (high) Lactate dehydrogenase 658 U/L (high) PT 18.5sec (high)

80 Clinical Lost 10# in 6 months o 7% weight loss Fatigued and weak Bruising of skin Hepatomegaly Telangiectasias (enlarged spider-like veins on the chest) Jaundice

81 Dietary Protein: 1.2 g/kg o 57 kg x 1.2 g/kg = 68.4 g protein Energy: kcal/kg o 57 kg x 37 kcal/kg = 2109 kcal Restrict sodium Restrict fluids Small, frequent meals Control CHO

82 PES Statement Inadequate nutrient intake related to loss of appetite as evidenced by 7% weight loss, and stated poor PO.

83 Sample Diet Breakfast AM Snack Lunch PM Snack Dinner HR Snack 3/4 cup cheerios 1 cup milk 1 peach 1 piece of toast 250 ml Nutrihep PB&J sandwich ½ cup carrot sticks 1 cheese stick 2 T hummus with pepper Apple 1 cup wild rice 3 oz grilled chicken breast 1 cup mixed green salad 1 T dressing Banana PB milkshake Calories: 2192 kcal Protein: 96 g Sodium: 2500 mg